10-Q

UNITED STATES

SECURITIES AND EXCHANGE COMMISSION

Washington, D.C. 20549

_________________________________________________________________

FORM 10-Q

_________________________________________________________________

(Mark One)

☒         QUARTERLY REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934

For the quarterly period ended June 30, 2023

or

☐        TRANSITION REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934

For the transition period from ___________ to ___________

Commission File Number: 001-38721

_________________________________________________________________

Axonics, Inc.

(Exact name of registrant as specified in its charter)

_________________________________________________________________

Delaware				45-4744083
(State or other jurisdiction of incorporation or organization)				(I.R.S. Employer Identification Number)
26 Technology Drive
Irvine,	California			92618
(Address of principal executive offices)				(Zip Code)
		(949)	396-6322
		(Registrant’s telephone number, including area code)

Securities registered pursuant to Section 12(b) of the Exchange Act:

Title of class	Trading symbol	Name of exchange on which registered
Common stock, par value $0.0001 per share	AXNX	Nasdaq Global Select Market

    Indicate by check mark whether the registrant (1) has filed all reports required to be filed by Section 13 or 15(d) of the Securities Exchange Act of 1934 during the preceding 12 months (or for such shorter period that the registrant was required to file such reports), and (2) has been subject to such filing requirements for the past 90 days.  Yes ☒     No ☐

    Indicate by check mark whether the registrant has submitted electronically every Interactive Data File required to be submitted pursuant to Rule 405 of Regulation S-T (§ 232.405 of this chapter) during the preceding 12 months (or for such shorter period that the registrant was required to submit such files).  Yes ☒    No ☐

    Indicate by check mark whether the registrant is a large accelerated filer, an accelerated filer, a non-accelerated filer, a smaller reporting company, or an emerging growth company. See the definitions of “large accelerated filer,” “accelerated filer,” “smaller reporting company,” and “emerging growth company” in Rule 12b-2 of the Exchange Act.

Large accelerated filer	☒	Accelerated filer	☐
Non-accelerated filer	☐	Smaller reporting company	☐
		Emerging growth company	☐

If an emerging growth company, indicate by check mark if the registrant has elected not to use the extended transition period for complying with any new or revised financial accounting standards provided pursuant to Section 13(a) of the Exchange Act.   ☐

Indicate by check mark whether the registrant is a shell company (as defined in Rule 12b-2 of the Exchange Act).  Yes ☐  No ☒

As of July 28, 2023, 50,460,801 shares of the registrant’s common stock, par value $0.0001 per share, were outstanding.

TABLE OF CONTENTS

		Page
	Special Note Regarding Forward-Looking Statements
	PART I—FINANCIAL INFORMATION
Item 1.	Condensed Consolidated Financial Statements (unaudited)	1
	Condensed Consolidated Balance Sheets	1
	Condensed Consolidated Statements of Comprehensive Loss	2
	Condensed Consolidated Statements of Stockholders’ Equity	3
	Condensed Consolidated Statements of Cash Flows	4
	Notes to Condensed Consolidated Financial Statements	5
Item 2.	Management’s Discussion and Analysis of Financial Condition and Results of Operations	25
Item 3.	Quantitative and Qualitative Disclosures About Market Risk	34
Item 4.	Controls and Procedures	35
	PART II—OTHER INFORMATION
Item 1.	Legal Proceedings	37
Item 1A.	Risk Factors	37
Item 2.	Unregistered Sales of Equity Securities and Use of Proceeds	37
Item 3.	Defaults Upon Senior Securities	37
Item 4.	Mine Safety Disclosures	37
Item 5.	Other Information	37
Item 6.	Exhibits	38
	Signatures	39

Special Note Regarding Forward-Looking Statements

This Quarterly Report on Form 10-Q contains forward-looking statements within the meaning of Section 27A of the Securities Act of 1933, as amended (the Securities Act), and Section 21E of the Securities Exchange Act of 1934, as amended (the Exchange Act), that involve risks and uncertainties, including statements based on our current expectations, assumptions, estimates and projections about future events, our business, financial condition, results of operations and prospects, our industry and the regulatory environment in which we operate. Any statements contained herein that are not statements of historical facts may be deemed to be forward-looking statements. In some cases, you can identify forward-looking statements by terms such as “anticipate,” “believe,” “could,” “estimate,” “expect,” “intend,” “may,” “plan,” “potential,” “predict,” “project,” “should,” “will,” “would” or the negative of those terms, or other comparable terms intended to identify statements about the future. Forward-looking statements include, but are not limited to, statements about:

•unanticipated safety concerns related to the use of our products;

•U.S. Food and Drug Administration (FDA) or other U.S. or foreign regulatory or legal actions or changes affecting us or our industry;

•the results of any ongoing or future legal proceedings, including but not limited to intellectual property, product liability or other litigation against us, our third-party manufacturers or other parties on which we rely or litigation against our general industry;

•any termination or loss of intellectual property rights;

•any voluntary or regulatory mandated product recalls;

•adverse developments concerning our manufacturers or suppliers or any future strategic partnerships;

•reduction or interruption in our supply chain and other possible inventory constraints or challenges;

•introductions and announcements of new technologies by us, any commercialization partners or our competitors, and the timing of these introductions and announcements;

•successful integration of acquired operations into our ongoing business;

•announcements of regulatory approval or disapproval of our products and any future enhancements to our products;

•adverse results from or delays in clinical studies of our products;

•variations in our financial results or those of companies that are perceived to be similar to us;

•success or failure of competitive products or therapies in the markets in which we do business;

•changes in the structure of healthcare payments for our products;

•announcements by us or our competitors of significant acquisitions, licenses, strategic partnerships, joint ventures or capital commitments;

•changes in macroeconomic and market conditions and volatility, including impacts related to the continued impact of the COVID-19 pandemic, risk of recession, inflation, supply chain constraints or disruptions and rising interest rates;

•economic and market conditions in general and in the medical technology industry specifically, including the size and growth, if any, of our markets, and the issuance of securities analysts’ reports or recommendations;

•rumors and market speculation involving us or other companies in our industry;

•sales of substantial amounts of our stock by directors, officers or significant stockholders, or the expectation that such sales might occur;

•additions or departures of key personnel; and

•changes in our capital structure, such as future issuances of securities and the incurrence of additional debt.

The forward-looking statements included herein are based on current expectations of our management based on available information and involve a number of risks and uncertainties, all of which are difficult or impossible to predict accurately and many of which are beyond our control. As such, our actual results may differ significantly from those expressed in any forward-looking statements. Factors that may cause or contribute to such differences include, but are not limited to, those discussed in more detail in Item 2 “Management’s Discussion and Analysis of Financial Condition and Results of Operations” of Part I and Item 1A “Risk Factors” of Part II of this Quarterly Report on Form 10-Q. Readers should carefully review these risks, as well as the additional risks described in other documents we file from time to time with the Securities and Exchange Commission (SEC). In light of the significant risks and uncertainties inherent in the forward-looking statements included herein, the inclusion of such information should not be regarded as a representation by us or any other person that such results will be achieved, and readers are cautioned not to place undue reliance on such forward-looking statements. Except as required by law, we undertake no obligation to revise the forward-looking statements contained herein to reflect events or circumstances after the date hereof or to reflect the occurrence of unanticipated events. You should read this Quarterly Report on Form 10-Q and the documents we file with the SEC, with the understanding that our actual future results, levels of activity, performance and achievements may be materially different from what we expect. We qualify all of our forward-looking statements by these cautionary statements.

Unless the context indicates otherwise, as used in this Quarterly Report on Form 10-Q, the terms “Axonics,” “our company,” “we,” “us” and “our” refer to Axonics, Inc. and our consolidated subsidiaries.

This Quarterly Report on Form 10-Q includes our trademarks and trade names, including, without limitation, Axonics R20™, Axonics F15™ and Bulkamid®, which are our property and are protected under applicable intellectual property laws. This Quarterly Report on Form 10-Q also includes trademarks and trade names that are the property of other organizations. Solely for convenience, trademarks and trade names referred to in this Quarterly Report on Form 10-Q appear without the ® and ™ symbols, but those references are not intended to indicate that we will not assert, to the fullest extent under applicable law, our rights, or that the applicable owner will not assert its rights, to these trademarks and trade names. We do not intend our use or display of other companies’ trade names or trademarks to imply a relationship with, or endorsement or sponsorship of us by, any other companies.

Part I—Financial Information

Item 1.    Condensed Consolidated Financial Statements (unaudited)

Axonics, Inc.

Condensed Consolidated Balance Sheets

(in thousands, except share and per share data)

	June 30,		December 31,
	2023		2022
	(unaudited)
ASSETS
Current assets
Cash and cash equivalents	$	145,343	$	238,846
Short-term investments	186,173		118,365
Accounts receivable, net of allowance for credit losses of $367 and $321 at June 30, 2023 and December 31, 2022, respectively	47,436		44,817
Inventory, net	70,083		55,765
Prepaid expenses and other current assets	6,361		7,282
Total current assets	455,396		465,075
Property and equipment, net	6,349		6,798
Intangible assets, net	85,543		86,253
Other assets	2,817		6,813
Goodwill	98,880		94,414
Total assets	$	648,985	$	659,353
LIABILITIES AND STOCKHOLDERS’ EQUITY
Current liabilities
Accounts payable	$	12,185	$	9,070
Accrued liabilities	5,571		6,520
Accrued compensation and benefits	12,559		15,495
Operating lease liability, current portion	1,769		1,562
Other current liabilities	—		32,600
Total current liabilities	32,084		65,247
Operating lease liability, net of current portion	1,199		7,555
Deferred tax liabilities, net	15,173		16,412
Total liabilities	48,456		89,214
Commitments and contingencies (Note 3)
Stockholders’ equity
Preferred stock, par value $0.0001 per share; 10,000,000 shares authorized, no shares issued and outstanding at June 30, 2023 and December 31, 2022	—		—
Common stock, par value $0.0001, 75,000,000 shares authorized at June 30, 2023 and December 31, 2022; 50,461,257 and 49,546,727 shares issued and outstanding at June 30, 2023 and December 31, 2022, respectively	5		5
Additional paid-in capital	1,009,704		969,545
Accumulated deficit	(390,854)		(374,264)
Accumulated other comprehensive loss	(18,326)		(25,147)
Total stockholders’ equity	600,529		570,139
Total liabilities and stockholders’ equity	$	648,985	$	659,353

See accompanying notes to unaudited condensed consolidated financial statements.

1

Axonics, Inc.

Condensed Consolidated Statements of Comprehensive Loss

(in thousands, except share and per share data)

(unaudited)

	Three Months Ended June 30,				Six Months Ended June 30,
	2023		2022		2023		2022
Net revenue	$	92,894	$	68,980	$	163,544	$	117,400
Cost of goods sold	22,704		18,784		40,854		33,962
Gross profit	70,190		50,196		122,690		83,438
Operating expenses
Research and development	8,949		7,135		17,005		18,371
General and administrative	10,713		10,572		22,881		20,585
Sales and marketing	44,270		39,381		86,924		72,444
Amortization of intangible assets	2,279		2,332		4,501		4,795
Acquisition-related costs	602		12,205		2,368		12,205
Acquired in-process research & development	15,447		—		15,447		—
Total operating expenses	82,260		71,625		149,126		128,400
Loss from operations	(12,070)		(21,429)		(26,436)		(44,962)
Other income (expense)
Interest and other income	4,250		360		7,878		403
Interest and other expense	174		(839)		857		(1,128)
Other income (expense), net	4,424		(479)		8,735		(725)
Loss before income tax benefit	(7,646)		(21,908)		(17,701)		(45,687)
Income tax benefit	(304)		(465)		(1,111)		(1,576)
Net loss	(7,342)		(21,443)		(16,590)		(44,111)
Foreign currency translation adjustment	3,750		(12,648)		6,821		(17,568)
Comprehensive loss	$	(3,592)	$	(34,091)	$	(9,769)	$	(61,679)
Net loss per share, basic and diluted (see Note 1)	$	(0.15)	$	(0.47)	$	(0.34)	$	(0.98)
Weighted-average shares used to compute basic and diluted net loss per share (see Note 1)	49,088,373		45,311,001		48,835,135		45,225,494

See accompanying notes to unaudited condensed consolidated financial statements.

2

Axonics, Inc.

Condensed Consolidated Statements of Stockholders’ Equity

(in thousands, except share and per share data)

(unaudited)

								Accumulated
				Additional				Other
	Common Stock			Paid-in		Accumulated		Comprehensive
	Shares	Amount		Capital		Deficit		Loss		Total
Balance at December 31, 2022	49,546,727	$	5	$	969,545	$	(374,264)	$	(25,147)	$	570,139
Issuance of common stock for employee stock option exercises for cash	116,452	—		1,930		—		—		1,930
Restricted Shares Award (RSA) issuances and forfeitures for terminations, net and stock-based compensation	247,770	—		7,295		—		—		7,295
Issuance of common stock for vesting of Restricted Stock Units (RSU) and stock-based compensation	199,718	—		3,419		—		—		3,419
Foreign currency translation adjustment	—	—		—		—		3,071		3,071
Net loss	—	—		—		(9,248)		—		(9,248)
Balance at March 31, 2023	50,110,667	5		982,189		(383,512)		(22,076)		576,606
Issuance of common stock for employee stock option exercises for cash	43,229	—		864		—		—		864
RSA issuances and forfeitures for terminations, net and stock-based compensation	42,578	—		7,676		—		—		7,676
Issuance of common stock for vesting of RSU and stock-based compensation	—	—		3,528		—		—		3,528
Issuance of common stock for acquisition of in-process research & development	264,783	—		15,447		—		—		15,447
Foreign currency translation adjustment	—	—		—		—		3,750		3,750
Net loss	—	—		—		(7,342)		—		(7,342)
Balance at June 30, 2023	50,461,257	$	5	$	1,009,704	$	(390,854)	$	(18,326)	$	600,529

								Accumulated
				Additional				Other
	Common Stock			Paid-in		Accumulated		Comprehensive
	Shares	Amount		Capital		Deficit		Loss		Total
Balance at December 31, 2021	46,330,167	$	5	$	803,559	$	(314,566)	$	(6,560)	$	482,438
Issuance of common stock for employee stock option exercises for cash	91,286	—		1,444		—		—		1,444
RSA issuances and forfeitures for terminations, net and stock-based compensation	312,479	—		5,633		—		—		5,633
Issuance of common stock for vesting of RSU and stock-based compensation	268,930	—		1,505		—		—		1,505
Foreign currency translation adjustment	—	—		—		—		(4,920)		(4,920)
Net loss	—	—		—		(22,668)		—		(22,668)
Balance at March 31, 2022	47,002,862	5		812,141		(337,234)		(11,480)		463,432
Issuance of common stock for employee stock option exercises for cash	35,803	—		480		—		—		480
RSA issuances and forfeitures for terminations, net and stock-based compensation	79,051	—		6,490		—		—		6,490
Issuance of common stock for vesting of RSU and stock-based compensation	—	—		1,415		—		—		1,415
Foreign currency translation adjustment	—	—		—		—		(12,648)		(12,648)
Net loss	—	—		—		(21,443)		—		(21,443)
Balance at June 30, 2022	47,117,716	$	5	$	820,526	$	(358,677)	$	(24,128)	$	437,726

See accompanying notes to unaudited condensed consolidated financial statements.

3

Axonics, Inc.

Condensed Consolidated Statements of Cash Flows

(in thousands)

(unaudited)

	Six Months Ended June 30,
	2023		2022
Cash Flows from Operating Activities
Net loss	$	(16,590)	$	(44,111)
Adjustments to reconcile net loss to net cash used in operating activities
Depreciation and amortization	6,041		5,920
Stock-based compensation	21,918		15,043
Acquired in-process research and development	15,447		—
Provision for (reversal of) allowance of credit losses	46		(50)
Change in fair value of contingent consideration	2,400		12,030
Deferred income taxes and other items, net	(1,700)		(1,638)
Changes in operating assets and liabilities
Accounts receivable	(2,556)		(7,260)
Inventory	(14,480)		6,220
Prepaid expenses and other current assets	(9)		1,514
Other assets	(1,868)		17
Accounts payable	2,968		2,153
Accrued liabilities	(968)		1,582
Accrued compensation and benefits	(2,945)		(1,465)
Lease liability	(324)		36
Other liabilities	(27,370)		—
Net cash used in operating activities	(19,990)		(10,009)
Cash Flows from Investing Activities
Purchases of property and equipment	(1,050)		(925)
Purchases of short-term investments	(174,616)		(9,998)
Proceeds from sales and maturities of short-term investments	107,737		—
Net cash used in investing activities	(67,929)		(10,923)
Cash Flows from Financing Activities
Payment of contingent consideration recognized at acquisition	(7,630)		—
Proceeds from exercise of stock options	2,794		1,924
Net cash (used in) provided by financing activities	(4,836)		1,924
Effect of exchange rate changes on cash and cash equivalents	(748)		1,366
Net decrease in cash and cash equivalents	(93,503)		(17,642)
Cash and cash equivalents, beginning of year	238,846		220,878
Cash and cash equivalents, end of period	$	145,343	$	203,236
Supplemental Disclosure of Cash Flow Information
Cash paid for interest	$	39	$	1
Cash paid for taxes	$	94	$	639
Noncash Investing and Financing Activities
Property and equipment acquired but not yet paid	$	41	$	513
Common stock issuance for acquired in-process research and development	$	15,447	$	—

See accompanying notes to unaudited condensed consolidated financial statements.

4

AXONICS, INC.

NOTES TO CONDENSED CONSOLIDATED FINANCIAL STATEMENTS

(Unaudited)

Note 1. Nature of Operations and Summary of Significant Accounting Policies

Nature of Operations

Axonics, Inc. (the Company) was incorporated in the state of Delaware on March 2, 2012 under the name American Restorative Medicine, Inc. The Company had no operations until October 1, 2013, when the license agreement between Alfred E. Mann Foundation for Scientific Research (AMF) and the Company (the License Agreement) was entered into. In August 2013, the Company changed its name to Axonics Modulation Technologies, Inc. In March 2021, the Company changed its name to Axonics, Inc.

The Company is a medical technology company that develops and commercializes innovative and minimally invasive products to treat bladder and bowel dysfunction. The Company has designed and developed both rechargeable (R20™) and recharge-free (F15™) implantable sacral neuromodulation (SNM) systems, which deliver mild electrical pulses to the targeted sacral nerve in order to restore normal communication to and from the brain to reduce the symptoms of overactive bladder (OAB), urinary retention (UR) and fecal incontinence (FI). The Company’s products are protected by intellectual property based on Company-generated innovations and patents and other intellectual property licensed from AMF. The Company has marketing approvals in the United States, Europe, Canada, and Australia for all relevant clinical indications. The premarket approval (PMA) application for the Company’s first rechargeable SNM system for the treatment of FI was approved by the U.S. Food and Drug Administration (FDA) on September 6, 2019, and the PMA application for the first rechargeable SNM system for the treatment of OAB and UR was approved by the FDA on November 13, 2019. Accordingly, the Company began U.S. commercialization of its first rechargeable SNM system in the fourth quarter of 2019.

Beginning in February 2021 with the acquisition of Contura Limited, the Company also markets Bulkamid®, a urethral bulking agent to treat female stress urinary incontinence (SUI). Beginning in March 2022 with the FDA approval of the Company’s long-lived, recharge-free F15 SNM implantable stimulator, the Company now markets and sells the F15 recharge-free system to customers in the United States in addition to the rechargeable SNM system. The new recharge-free SNM system and Bulkamid are protected by intellectual property based on Company-generated innovations or patents acquired as part of the Contura acquisition.

August 2022 Follow-On Offering

On August 5, 2022, the Company completed a follow-on offering by issuing 2,012,500 shares of common stock, at an offering price of $63.85 per share, inclusive of 262,500 shares of the Company’s common stock issued upon the exercise by the underwriters of their option to purchase additional shares. The net proceeds to the Company were approximately $128.3 million, after deducting offering expenses payable by the Company.

Acquisition of in-process research & development from Radian, LLC

In April 2023, the Company acquired the assets of Radian, LLC (the Seller), for total consideration of the issuance of 264,783 shares of common stock and a potential future milestone payment of up to $2.5 million (the Radian acquisition).

The Company evaluated this acquisition in accordance with Accounting Standards Codification (ASC) 805, Business Combinations, to determine whether the asset acquired met the definition of a business. Included in the IPR&D is the historical know-how, software, formula protocols, designs, and procedures expected to be needed to complete the technology asset and receive regulatory approval. The Company concluded that the IPR&D is an identifiable intangible asset that would be accounted for as a single asset in a business combination. The Company also qualitatively concluded that there is no fair value associated with any other assets included in the acquisition. Therefore, all of the consideration in the transaction was allocated to the IPR&D. As such, the Company concluded that substantially all of the fair value of the gross assets acquired was concentrated in the single IPR&D asset and the set was not a business.

The Company is planning to use the acquired IPR&D technology to provide a solution to make peripheral nerve evaluation lead placement easier, faster, and more accurate. Although the acquired technology may have utility in other medical procedures, future development decisions for the acquired technology will be contingent upon the receipt of required regulatory approvals. As such, the acquired technology does not have an alternative

5

future use at the acquisition date. In accordance with ASC 730, Research and Development, the Company concluded the entire purchase price for the asset acquisition was an expense on the acquisition date.

The consideration transferred at closing had an acquisition date fair value of $15.4 million based on a per share value of $58.34 on the acquisition date and was recognized immediately as IPR&D expense in the unaudited condensed consolidated statements of comprehensive loss for the three and six months ended June 30, 2023. The potential future milestone payment of $2.5 million, payable in either cash or shares of common stock, will become payable upon the Company receiving from the FDA 510(k) clearance for the acquired IPR&D technology.

Principles of Consolidation

The accompanying unaudited interim condensed consolidated financial statements include the accounts of the Company and its wholly-owned subsidiaries: Axonics Europe, S.A.S., Axonics Modulation Technologies U.K. Limited, Axonics Modulation Technologies Australia Pty Ltd, Axonics Women’s Health Limited, Bulkamid SARL, Axonics GmbH, and Contura, Inc. Intercompany accounts and transactions have been eliminated in consolidation.

Basis of Presentation and Liquidity

Interim Financial Statements

The unaudited interim condensed consolidated financial statements and related footnote disclosures as of and for the three and six months ended June 30, 2023 are unaudited, and are not necessarily indicative of the Company’s operating results for a full year. The unaudited interim condensed consolidated financial statements include all normal and recurring adjustments necessary for a fair presentation of the Company’s financial results for the three and six months ended June 30, 2023 in accordance with United States generally accepted accounting principles (GAAP), however, certain information and footnote disclosures normally included in annual financial statements prepared in accordance with GAAP have been condensed or omitted pursuant to the U.S. Securities and Exchange Commission (SEC) rules and regulations relating to interim financial statements. The accompanying unaudited condensed consolidated financial statements should be read in conjunction with the Company’s audited consolidated financial statements and notes thereto included within the Company’s Annual Report on Form 10-K for the fiscal year ended December 31, 2022 (filed with the SEC on March 1, 2023).

Liquidity

The Company began full-scale commercialization of its first r-SNM System in late 2019. The Company has expended significant resources on research and development activities, growing its operations organization and building and training its sales organization.

The Company incurred net losses of $16.6 million and $44.1 million for the six months ended June 30, 2023 and 2022, respectively, and had an accumulated deficit of $390.9 million as of June 30, 2023 compared to $374.3 million at December 31, 2022. The Company expects to continue to spend a significant amount of its existing resources on sales and marketing activities as the Company continues to invest in commercializing and marketing its products in the United States and internationally.

As of June 30, 2023, the Company had cash, cash equivalents, and short-term investments of $331.5 million compared to $357.2 million at December 31, 2022. The Company expects that its cash, cash equivalents, and short-term investments on hand will be sufficient to fund its operations through at least the next 12 months. The Company funds its operations through a combination of proceeds from public offerings of its common stock and cash receipts from sales of its products. As of June 30, 2023, the Company had no outstanding borrowings.

The Company may need to raise additional financing in the future to facilitate its business operations. If the Company raises additional funds by issuing equity securities, its stockholders could experience dilution. Debt financing, if available, may involve covenants further restricting its operations or its ability to incur additional debt. Any debt financing or additional equity that the Company raises may contain terms that are not favorable to the Company or its stockholders. Additional financing may not be available at all, or in amounts or on terms acceptable to the Company. If the Company is unable to obtain additional financing when needed to satisfy its liquidity requirements, the Company may be required to scale back its operations.

6

Use of Estimates

The preparation of unaudited condensed consolidated financial statements in conformity with GAAP requires the Company’s management to make estimates and judgments that affect the reported amounts of assets, liabilities, and expenses, and related disclosures of contingent assets and liabilities. The Company bases its estimates on historical experience and on various other assumptions that it believes to be reasonable under the circumstances. The results of this evaluation then form the basis for making judgments about the carrying values of assets and liabilities that are not readily apparent from other sources. Actual results may differ from these estimates, and such differences may be material to the consolidated financial statements. Significant items subject to such estimates and assumptions include the useful lives of property and equipment and intangible assets, the valuation of deferred income tax assets and liabilities, the valuation of contingent consideration liability, the valuation of stock-based compensation, the product returns reserve, the inventory obsolescence reserve and accounts receivable allowance for credit losses.

Revenue Recognition

Revenue recognized during the six months ended June 30, 2023 and 2022 relates entirely to the sale of the Company’s products to its customers and distributors.

The Company has revenue arrangements that consist of a single performance obligation. The Company recognizes revenue at the point in time when it transfers control of promised goods to its customers. Revenue is measured as the amount of consideration expected to be received in exchange for transferring goods. The amount of revenue that is recognized is based on the transaction price, which represents the invoiced amount and includes estimates of variable consideration such as discounts, where applicable. The Company also sells to distributors and applies the same policies as its revenue arrangements with customers, specifically that revenue is recognized at the point in time when it transfers control of promised goods to its distributors. The Company does not offer rights of return or price protection. The amount of variable consideration included in the transaction price may be constrained and is included only to the extent that it is probable that a significant reversal in the amount of the cumulative revenue recognized under the contract will not occur in a future period. Payment terms, typically less than three months, do not include a significant financing component. The Company extends credit to its customers and distributors based upon an evaluation of their financial condition and credit history and generally requires no collateral. The Company does not have any contract balances related to product sales. The Company also does not have significant contract acquisition costs related to product sales.

In accordance with Company policy and based on the Company’s historical experience, the allowance for product returns was $0.2 million and $0.2 million at June 30, 2023 and December 31, 2022, respectively, and is recorded as a reduction of gross revenue in its unaudited condensed consolidated statements of comprehensive loss. Damaged or defective products are replaced at no charge under the Company’s standard warranty. For the three and six months ended June 30, 2023, the replacement costs were minimal and $0.1 million, respectively. For the three and six months ended June 30, 2022, the replacement costs were minimal and $0.1 million, respectively. The replacement costs are recorded within the sales and marketing expenses in its unaudited condensed consolidated statements of comprehensive loss.

The Company offers its standard warranty to all customers. The Company does not sell any warranties on a standalone basis. The Company’s warranty provides that its products are free of material defects and conform to specifications, and includes an offer to repair, replace or refund the purchase price of defective products. This assurance does not constitute a service and is not considered a separate performance obligation. The Company estimates warranty liabilities at the time of revenue recognition and records it as a charge to sales and marketing expense. The warranty liability as of June 30, 2023 and December 31, 2022 was $0.1 million and $0.1 million, respectively.

Shipping and handling costs incurred for the delivery of goods to customers and distributors are included in cost of goods sold. Amounts billed to customers and distributors for shipping and handling are included in net revenue.

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The following table provides additional information pertaining to net revenue disaggregated by product and geographic market for the three and six months ended June 30, 2023 and 2022 (in thousands):

	Three Months Ended June 30,				Six Months Ended June 30,
	2023		2022		2023		2022
SNM net revenue
United States	$	72,205	$	54,468	$	126,058	$	92,183
International markets	1,983		1,290		3,288		2,645
	$	74,188	$	55,758	$	129,346	$	94,828
Bulkamid net revenue
United States	$	14,806	$	10,223	$	26,419	$	16,792
International markets	3,900		2,999		7,779		5,780
	$	18,706	$	13,222	$	34,198	$	22,572
Total net revenue	$	92,894	$	68,980	$	163,544	$	117,400

Allowance for Credit Losses

The Company makes estimates of the collectability of accounts receivable in accordance with Accounting Standards Update (ASU) 2016-13, “Financial Instruments—Credit Losses (Topic 326): Measurement of Credit Losses on Financial Instruments.” The Company’s estimate of future credit losses is made by management based upon historical bad debts, customer receivable balances, age of customer receivable balances, customers’ financial conditions and reasonable forecasted economic trends. Despite the Company’s efforts to minimize credit risk exposure, customers could be adversely affected if future economic and industry trends change in such a manner as to negatively impact their cash flows. As a result, the Company’s future collection experience can differ significantly from historical collection trends. If the Company’s customers experience a negative impact on their cash flows, it could have a material adverse effect on the Company’s results of operations and financial condition.

The following table summarizes the changes in our allowance for credit losses (in thousands):

	Six Months Ended June 30,
	2023		2022
Balance at beginning of period	$	321	$	355
Write-offs	—		—
Bad debt expense (recoveries)	46		(50)
Balance at end of period	$	367	$	305

Cash and Cash Equivalents

Cash equivalents consist of short-term, highly liquid investments purchased with a maturity of three months or less. Financial instruments that potentially subject the Company to a concentration of credit risk consist of cash and cash equivalents. At times, the cash and cash equivalent balances may exceed federally insured limits. The Company does not believe that this results in any significant credit risk as the Company’s policy is to place its cash and cash equivalents in highly-rated financial institutions. The Company also holds cash in foreign banks that are not federally insured. The Company has not experienced any losses on its deposits of cash and cash equivalents.

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Fair Value of Financial Instruments

Fair value is defined as the price that would be received to sell an asset or paid to transfer a liability in an orderly transaction between market participants at the measurement date. A three-level fair value hierarchy prioritizes the inputs used to measure fair value. The hierarchy requires entities to maximize the use of observable inputs and minimize the use of unobservable inputs. The three levels of inputs used to measure fair value are as follows:

•Level 1: Inputs are unadjusted quoted prices in active markets for identical assets or liabilities.

•Level 2: Inputs are quoted prices for similar assets and liabilities in active markets or quoted prices for identical or similar instruments in markets that are not active and model-derived valuations in which all significant inputs and significant value drivers are observable in active markets.

•Level 3: Inputs are unobservable inputs based on the Company’s assumptions and valuation techniques used to measure assets and liabilities at fair value. The inputs require significant management judgment or estimation.

Level 1 investments include U.S. government and agency securities, which are valued based on prices readily available in the active markets in which those securities are traded. Level 2 investments include commercial paper and corporate notes, which is valued on a recurring basis based on inputs that are readily available in public markets or can be derived from information available in publicly quoted markets.

The Company’s assessment of the significance of an input to the fair value measurement requires judgment, which may affect the valuation of fair value assets and liabilities and their placement within the fair value hierarchy levels. The carrying amounts reported in the unaudited condensed consolidated financial statements approximate the fair value for cash and cash equivalents, accounts receivable, and accounts payables, due to their short-term nature.

The purchase price of business acquisitions is primarily allocated to the tangible and identifiable intangible assets acquired and liabilities assumed based on their estimated fair values on the acquisition date, with the excess recorded as goodwill.

Certain of the Company’s business combinations involve potential payment of future consideration that is contingent upon the achievement of certain product development milestones and/or contingent on the acquired business reaching certain performance milestones. A liability is recorded for the estimated fair value of the contingent consideration on the acquisition date. The fair value of the contingent consideration is remeasured at each reporting period, and the change in fair value is recognized within operating expenses in the consolidated statements of comprehensive loss.

On February 25, 2021, the Company acquired Contura Limited and its Bulkamid product, a urethral bulking agent indicated for the treatment of female SUI. In consideration for the acquisition, the Company paid approximately $141.3 million in cash and issued 1,096,583 shares of our common stock. The agreement also provided that the Company may pay an additional $35 million in the event Bulkamid sales in any consecutive 12-month period exceed $50 million (the Milestone) before December 31, 2024, with payment due within 50 business days following the quarter in which the Milestone has been met.

Contingent consideration represents contingent milestone, performance and revenue-sharing payment obligations related to acquisitions and is measured at fair value, based on significant inputs not observable in the market, which represents a Level 3 measurement within the fair value hierarchy. The valuation of contingent consideration is estimated using a binary option-based approach with assumptions the Company believes would be made by a market participant. Significant inputs include projected revenues, discount rates, volatility factors and risk-free rates. The Company assesses these assumptions on an ongoing basis as additional data impacting the assumptions is obtained and any change in fair value of the contingent consideration is recorded within acquisition-related costs in the consolidated statements of comprehensive loss. Significant increases or decreases in any of those inputs in isolation would result in a significantly lower or higher fair value measurement. Generally, a change in the assumption used for the projected revenues would result in a directionally similar change to the overall estimate of the contingent consideration. At March 31, 2023, the Milestone has been met and payment was made during the three months ended June 30, 2023. The fair value of contingent consideration of $32.6 million at December 31,

9

2022, is reflected in other current liabilities in the Company’s unaudited condensed consolidated balance sheets.

The following table summarizes the changes in the fair value of recurring Level 3 fair value measurements during the six months ended June 30, 2023 and 2022 (in thousands):

	Six Months Ended June 30,
	2023		2022
Liabilities
Contingent consideration:
Balance at beginning of period	$	32,600	$	10,370
Change in fair value included in earnings	2,400		12,030
Payment made	(35,000)		—
Balance at end of period	$	—	$	22,400

There were no transfers between Levels 1, 2 or 3 for the periods presented.

Investment Securities

The Company classifies its investment securities as available-for-sale. Those investments in debt securities with maturities less than 12 months at the balance sheet date are considered short-term investments. Those investments in debt securities with maturities greater than 12 months at the balance sheet date are considered long-term investments. The Company’s investment securities classified as available-for-sale are recorded at fair value based on the fair value hierarchy (Level 1 and Level 2 inputs in the fair value hierarchy), and consists primarily of commercial paper, corporate notes and U.S. government and agency securities. Unrealized gains or losses, deemed temporary in nature, are reported as other comprehensive income (loss) within the unaudited condensed consolidated statements of comprehensive loss. There were no unrealized gains or losses during the three and six months ended June 30, 2023 and 2022.

A decline in the fair value of any security below cost that is deemed other than temporary results in a charge to net income (loss) and the corresponding establishment of a credit loss allowance for the security. Premiums (discounts) are amortized (accreted) over the life of the related security as an adjustment to yield using the straight-line interest method. Dividend, accretion and interest income are recognized when earned. Realized gains or losses are included in net loss and are derived using the specific identification method for determining the cost of securities sold.

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The following table presents the fair value hierarchy for those assets measured at fair value on a recurring basis as of June 30, 2023 and December 31, 2022 (in thousands):

	Fair Value Measurements at June 30, 2023
Assets:	Level 1		Level 2		Level 3		Total
Commercial paper	$	—	$	119,763	$	—	$	119,763
Corporate notes	—		5,700		—		5,700
U.S. government and agency securities	171,760		—		—		171,760
	$	171,760	$	125,463	$	—	$	297,223

_____________________________________________

(1)    As of June 30, 2023, commercial paper investments of $81.1 million and U.S. government and agency securities of $30.0 million are included in cash and cash equivalents on the unaudited condensed consolidated balance sheets, as the investments had a maturity of three months or less from the date of purchase.

	Fair Value Measurements at December 31, 2022
Assets:	Level 1		Level 2		Level 3		Total
Commercial paper	$	—	$	175,548	$	—	$	175,548
Corporate notes	—		4,675		—		4,675
U.S. government and agency securities	75,212		—		—		75,212
	$	75,212	$	180,223	$	—	$	255,435

_____________________________________________

(1)    As of December 31, 2022, commercial paper investments of $131.1 million, U.S. government and agency securities of $4.0 million, and corporate notes of $2.0 million are included in cash and cash equivalents on the unaudited condensed consolidated balance sheets, as the investments had a maturity of three months or less from the date of purchase.

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The Company holds investments in marketable debt securities that are classified and accounted for as cash equivalents or available-for-sale and are remeasured on a recurring basis. All of the Company’s available-for-sale debt securities are classified on the unaudited condensed consolidated balance sheets as cash equivalents or short-term investments. The following table summarizes the Company’s cash equivalents and investments in available-for-sale debt securities by significant investment category as of June 30, 2023 and December 31, 2022 (in thousands):

	June 30, 2023
	Cost		Unrealized gains		Unrealized losses		Fair value
Cash equivalents:
Commercial paper	$	81,063	$	—	$	—	$	81,063
Corporate notes	—		—		—		—
U.S. government and agency securities	29,987		—		—		29,987
Total cash equivalents	$	111,050	$	—	$	—	$	111,050
Short-term investments:
Commercial paper	$	38,700	$	—	$	—	$	38,700
Corporate notes	5,709		—		(9)		5,700
U.S. government and agency securities	141,805		3		(35)		141,773
Total short-term investments	$	186,214	$	3	$	(44)	$	186,173
Total	$	297,264	$	3	$	(44)	$	297,223

	December 31, 2022
	Cost		Unrealized gains		Unrealized losses		Fair value
Cash equivalents:
Commercial paper	$	131,075	$	—	$	—	$	131,075
Corporate notes	2,013		—		—		2,013
U.S. government and agency securities	3,982		—		—		3,982
Total cash equivalents	$	137,070	$	—	$	—	$	137,070
Short-term investments:
Commercial paper	$	44,473	$	—	$	—	$	44,473
Corporate notes	2,664		—		(2)		2,662
U.S. government and agency securities	71,342		6		(118)		71,230
Total short-term investments	$	118,479	$	6	$	(120)	$	118,365
Total	$	255,549	$	6	$	(120)	$	255,435

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Foreign Currency Translation

The functional currencies of the Company’s subsidiaries are currencies other than the U.S. dollar. The Company translates assets and liabilities of the foreign subsidiaries into U.S. dollars at the exchange rate in effect on the balance sheet date. Revenue and expenses of the subsidiaries are translated into U.S. dollars at the average exchange rate during the period. Gains or losses from these translation adjustments are reported as a separate component of stockholders’ equity in accumulated other comprehensive gain or loss until there is a sale or complete or substantially complete liquidation of the Company’s investment in the foreign subsidiary at which time the gains or losses will be realized and included in net income (loss). As of June 30, 2023 and December 31, 2022, all foreign currency translation gains (losses) have been unrealized and included in accumulated other comprehensive loss.

Inventory, Net

Inventories are stated at the lower of cost or net realizable value, with cost computed on a first-in, first-out basis. The Company reduces the carrying value of inventories for items that are potentially excess, obsolete, or slow-moving based on changes in customer demand, technology developments, or other economic factors.

The Company capitalizes inventory produced for commercial sale. The Company capitalizes manufacturing costs as inventory following both the receipt of regulatory approval from regulatory bodies and the Company’s intent to commercialize. Costs associated with developmental products prior to satisfying the Company’s inventory capitalization criteria are charged to research and development expenses as incurred.

Products that have been approved by certain regulatory authorities may also be used in clinical programs to assess the safety and efficacy of the products for usage that have not been approved by the FDA or other regulatory authorities. The form of product utilized for both commercial and certain clinical programs that are identical are included as inventory with an “alternative future use” as defined in authoritative guidance. Component materials and purchased products associated with clinical development programs are included in inventory and charged to research and development expenses when the product enters the research and development process and no longer can be used for commercial purposes and, therefore, does not have an “alternative future use.”

For products that are under development and have not yet been approved by regulatory authorities, purchased component materials are charged to research and development expenses when the inventory ownership transfers to the Company.

The Company analyzes inventory levels to identify inventory that may expire prior to sale, inventory that has a cost basis in excess of its net realizable value, or inventory in excess of expected sales requirements. Although the manufacturing of the Company’s SNM systems is subject to strict quality control, certain batches or units of product may no longer meet quality specifications or may expire, which would require adjustments to the Company’s inventory values. The Company also applies judgment related to the results of quality tests that are performed throughout the production process, as well as the understanding of regulatory guidelines, to determine if it is probable that inventory will be saleable. These quality tests are performed throughout the pre- and post-production processes, and the Company continually gathers information regarding product quality for periods after the manufacturing date. The Company’s products currently have a maximum estimated shelf life range of 12 to 36 months and based on sales forecasts, the Company expects to realize the carrying value of the product inventory. In the future, reduced demand, quality issues, or excess supply beyond those anticipated by management may result in a material adjustment to inventory levels, which would be recorded as an increase to cost of sales.

The determination of whether inventory costs will be realizable or not requires estimates by the Company’s management. A critical input in this determination is future expected inventory requirements based on internal sales forecasts. Management then compares these requirements to the expiry dates of inventory on hand. To the extent that inventory is expected to expire prior to being sold, management will write down the value of inventory.

As of June 30, 2023, the Company had $37.9 million, $9.5 million and $22.7 million of finished goods inventory, work-in-process inventory and raw materials inventory, respectively, net of reserves of $0.9 million. As of December 31, 2022, the Company had $30.4 million, $5.7 million and $19.7 million of finished goods inventory, work-in-process inventory and raw materials inventory, respectively, net of reserves of $0.5 million.

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Customer and Vendor Concentration

As of June 30, 2023 and December 31, 2022, there were no customers who accounted for over 10% of the Company’s consolidated accounts receivable. As of June 30, 2023 and December 31, 2022, there were three vendors and one vendor, respectively, who accounted for over 10% of the Company’s consolidated accounts payable. During the six months ended June 30, 2023 and 2022, there were no customers who accounted for over 10% of the Company’s consolidated net revenue. During the six months ended June 30, 2023 and 2022, there were three vendors and three vendors, respectively, who accounted for over 10% of the Company’s inventory-related purchases.

Property and Equipment

Property and equipment are stated at cost less accumulated depreciation. Depreciation is computed using the straight-line method over the estimated useful lives of the assets, generally between three and seven years. Leasehold improvements are amortized over the lesser of the life of the lease or the useful life of the improvements. Maintenance and repairs are charged to expense as incurred. When assets are retired or otherwise disposed of, the cost and accumulated depreciation are removed from the balance sheet and any resulting gain or loss is reflected in operations.

Goodwill

Goodwill represents the excess purchase price over the fair values of both tangible and intangible assets acquired less the liabilities assumed. Goodwill is tested for impairment at the reporting unit level by comparing the reporting unit’s carrying amount to the fair value of the reporting unit. The fair values are estimated using an income and discounted cash flow approach. The Company evaluates its goodwill on an annual basis in the fourth quarter or more frequently if it believes indicators of impairment exist. The Company assesses qualitative factors to determine whether it is more likely than not that the fair value of a reporting unit is less than its carrying amount or performs an annual impairment test. When tested quantitatively, the Company compares the fair value of the applicable reporting unit with its carrying value. In making this assessment, management relies on a number of factors, including expected future operating results, business plans, economic projections, anticipated future cash flows, business trends and declines in the Company’s market capitalization. The Company estimates the fair value of its reporting unit using a combination of the discounted cash flow and income approaches. If the carrying amount of a reporting unit exceeds the reporting unit’s fair value, the amount by which the carrying value exceeds the fair value is recognized as an impairment loss. During the six months ended June 30, 2023 and 2022, the Company did not record any impairment charges related to goodwill.

Intangible Assets

Patent license asset

The intangible asset represents exclusive rights to an additional field-of-use on the patent suite within the License Agreement with AMF. The additional field-of-use was provided in exchange for 50,000 shares of Series A preferred stock, the fair value of which was $1.0 million in 2013. The intangible asset was recorded at its fair value of $1.0 million at the date contributed. In connection with the initial public offering, such shares of Series A preferred stock were converted into common stock. Amortization of this asset is recorded over the shorter of the patent or legal life on a straight-line basis. The weighted-average amortization period is 8.71 years. The asset has been fully amortized as of June 30, 2023. For additional information, see Note 7.

Exclusive license asset

The intangible asset represents exclusive rights to existing technologies and development services from Micro Systems Engineering, Inc. pursuant to an agreement entered into on March 2, 2021. The rights and services were provided in exchange for 65,594 shares of common stock, the fair value of which was $3.6 million upon transfer. The intangible asset was recorded at its fair value of $3.3 million at the date of the agreement, with the difference of $0.3 million recorded as a vendor credit in accounts payable in the unaudited condensed consolidated balance sheets. Amortization of this asset is recorded over the four-year term of the agreement on a straight-line basis. The Company recorded expense for the amortization of the exclusive license asset of $0.2 million and $0.4 million during the three and six months ended June 30, 2023. The Company recorded expense for the amortization of the exclusive license asset of $0.2 million and $0.4 million during the three and six months ended

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June 30, 2022. The Company will review the intangible asset for impairment whenever an impairment indicator exists. There have been no intangible asset impairment charges to date. For additional information, see Note 7.

Contura acquisition

The intangible assets represent technology, trade names and trademarks, and customer relationships acquired from Contura on February 25, 2021. The trade names and trademarks have an indefinite life. The straight-line method over the period of estimated benefit is used to amortize technology. ASC 350-30-35-3 states that customer relationships generally dissipate at a more rapid rate in the earlier periods following a company’s succession to these relationships, with the rate of attrition declining over time. As such, the accelerated method is used to amortize customer relationships. The Company recorded expense for the amortization of Contura acquisition intangible assets of $2.0 million and $4.1 million during the three and six months ended June 30, 2023, respectively. The Company recorded expense for the amortization of Contura acquisition intangible assets of $2.1 million and $4.3 million during the three and six months ended June 30, 2022, respectively. The Company reviewed the intangible assets for impairment for this asset group during the six months ended June 30, 2023. As Bulkamid SARL ceased sales operations and did not recognize revenue during the year ended December 31, 2022, and does not expect to recognize revenue in future periods, the Company wrote off the customer relationships intangible asset of $0.3 million related to this entity during the year ended December 31, 2022. The impairment expense is recorded within the general and administrative expenses in its unaudited condensed consolidated statements of comprehensive loss. For additional information, see Note 7.

Impairment of Long-Lived Assets

The Company reviews its long-lived assets for impairment whenever events or changes in circumstances indicate that the carrying amount of an asset may not be recoverable. Recoverability is measured by comparing the carrying amount to the future net cash flows that the assets are expected to generate. If said assets are considered to be impaired, the impairment that would be recognized is measured by the amount by which the carrying amount of the assets exceeds the projected discounted future net cash flows arising from the asset. There have been $0.3 million of impairments of long-lived assets to date.

Indefinite-lived intangible assets are tested for impairment annually in the fourth quarter of the fiscal year and whenever events or changes in circumstances indicate that the carrying amount may be impaired. Impairment is calculated as the excess of the asset’s carrying value over its fair value. Fair value is generally determined using a discounted future cash flow analysis. There have been no impairments to indefinite-lived intangible assets during the six months ended June 30, 2023.

Leases

In accordance with ASU No. 2016-02, “Leases (Topic 842),” components of a lease should be split into three categories: lease components, non-lease components, and non-components. The fixed and in-substance fixed contract consideration (including any consideration related to non-components) must be allocated based on the respective relative fair values to the lease components and non-lease components. Entities may elect not to separate lease and non-lease components. Rather, entities would account for each lease component and related non-lease component together as a single lease component. The Company has elected to account for lease and non-lease components together as a single lease component for all underlying assets and allocate all of the contract consideration to the lease component only. Topic 842 allows for the use of judgment in determining whether the assumed lease term is for a major part of the remaining economic life of the underlying asset and whether the present value of lease payments represents substantially all of the fair value of the underlying asset. The Company applies the bright line thresholds referenced in Topic 842 to assist in evaluating leases for appropriate classification between operating and finance leases. The aforementioned bright lines are applied consistently to the Company’s entire portfolio of leases.

Operating lease right-of-use (ROU) assets and operating lease liabilities are recognized based on the present value of the future minimum lease payments over the lease term at commencement date. As the Company’s leases do not provide an implicit rate, the Company uses its incremental borrowing rate, which is the rate for a fully collateralized amortizing loan with the same maturity as the lease term in similar economic environment, based on the information available at commencement date in determining the present value of future payments. The operating lease ROU assets also include any lease payments made and excludes lease incentives and initial direct costs

15

incurred. The lease terms may include options to extend or terminate the lease when it is reasonably certain that the Company will exercise that option. Lease expense for minimum lease payments is recognized on a straight-line basis over the lease term.

Research and Development

Research and development costs are charged to operations as incurred. Research and development costs include salary and personnel-related costs, costs of clinical studies and testing, royalty expense, supplies and materials, and outside consultant costs.

Advertising Expense

The Company expenses advertising costs as they are incurred. During the three and six months ended June 30, 2023, advertising expense totaled $4.1 million and $8.4 million, respectively, and are recorded within the sales and marketing expenses in its unaudited condensed consolidated statements of comprehensive loss. During the three and six months ended June 30, 2022, advertising expense totaled $6.3 million and $9.5 million, respectively, and are recorded within the sales and marketing expenses in its unaudited condensed consolidated statements of comprehensive loss.

Income Taxes

The Company accounts for income taxes using the asset and liability method to compute the difference between the tax basis of assets and liabilities and the related financial amounts, using currently enacted tax rates. The Company has net deferred tax assets in certain jurisdictions. The realization of these deferred tax assets is dependent upon the Company’s ability to generate sufficient taxable income in future years. Valuation allowances are established, when necessary, to reduce deferred tax assets to the amount that more likely than not will be realized. The Company evaluates the recoverability of the deferred tax assets annually, and maintains a full valuation allowance on its U.S. net deferred tax assets. The Company recognizes the tax benefit from an uncertain tax position only if it is more likely than not that the tax position will be sustained on examination by taxing authorities, based on the technical merits of the position. The Company is subject to transfer pricing and other tax regulations designed to ensure that appropriate levels of income are reported as earned by the Company’s U.S. and foreign entities and are taxed accordingly. In the normal course of business, the Company is audited by federal, state and foreign tax authorities, and subject to inquiries from those tax authorities regarding the amount of taxes due. These inquiries may relate to the timing and amount of deductions and the allocation of income among various tax jurisdictions. The Company’s policy is to recognize interest and penalties related to unrecognized tax benefits, if any, in income tax expense.

Stock-Based Compensation

The Company measures the cost of employee and non-employee services in exchange for an award of equity instruments based on the grant-date fair value of the award and recognizes compensation cost over the requisite service period (typically the vesting period), generally three or four years. Forfeitures are estimated at the time of the grant and revised in subsequent periods to reflect differences between the estimates and the number of shares that actually become exercisable.

The Company uses the Black-Scholes option pricing model to determine the fair value of stock options (as of the date of grant) that have service conditions for vesting. Stock options and restricted shares awards vest based on service conditions, typically over three or four years.

The Company also grants shares of performance-based restricted stock units that typically vest after one year only if the Company has also achieved certain performance objectives as defined and approved by the Company’s board of directors. The fair value of performance awards is determined based on the Company’s stock price at the date of grant and expensed over the performance period based on the probability of achieving the performance objectives. If such targets are not met or service is not rendered for the requisite service period, no compensation cost is recognized, and any recognized compensation cost in prior periods will be reversed. In addition, the Company also grants market-based restricted stock units that have combined market conditions and service conditions for vesting, for which the Company uses the Monte Carlo valuation model to value equity awards (as of the date of grant). Compensation cost is not adjusted if the market condition is not met, as long as the requisite service is provided.

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Net Loss per Share of Common Stock

Basic net loss per share of common stock is calculated by dividing the net loss attributable to common stockholders by the weighted-average number of shares of common stock outstanding during the period, without consideration for potentially dilutive securities. Diluted net loss per share is computed by dividing the net loss attributable to common stockholders by the weighted-average number of shares of common stock and potentially dilutive securities outstanding for the period. For purposes of the diluted net loss per share calculation, common stock options, unvested RSAs and RSUs are considered to be potentially dilutive securities. Because the Company has reported a net loss in all periods presented, diluted net loss per share of common stock is the same as basic net loss per share of common stock for those periods.

For the three and six months ended June 30, 2023, there were 2,124,449 and 2,144,301 potentially dilutive weighted-average shares, respectively, that were not included in the computation of diluted weighted-average shares of common stock and common stock equivalent shares outstanding because their effect would have been antidilutive given the Company’s net loss. For the three and six months ended June 30, 2022, there were 2,403,317 and 2,414,973 potentially dilutive weighted-average shares, respectively, that were not included in the computation of diluted weighted-average shares of common stock and common stock equivalent shares outstanding because their effect would have been antidilutive given the Company’s net loss.

Segment Reporting

Operating segments are defined as components of an entity for which separate financial information is available and that is regularly reviewed by the Chief Operating Decision Maker (CODM) in deciding how to allocate resources to an individual segment and in assessing performance. The Company’s CODM is its Chief Executive Officer. The Company has determined it operates in one segment, the development and commercialization of innovative and minimally invasive products to treat bladder and bowel dysfunction. Geographically, the Company sells over 90% of its products to customers in the United States. Segment information is consistent with how management reviews the business, makes investing and resource allocation decisions and assesses operating performance.

Recent Accounting Pronouncements

We have reviewed and considered all recent accounting pronouncements that have not yet been adopted and believe there are none that could potentially have a material impact on our business practices, financial condition, results of operations, or disclosures.

Note 2. Property and Equipment, Net

Property and equipment, net consists of the following (in thousands) at:

	June 30,		December 31,
	2023		2022
Equipment	$	2,782	$	2,645
Computer hardware and software	3,295		3,282
Tools and molds	2,225		1,735
Leasehold improvements	4,449		4,449
Furniture and fixtures	1,874		1,810
Construction in progress	794		413
	15,419		14,334
Less: accumulated depreciation and amortization	(9,070)		(7,536)
	$	6,349	$	6,798

Depreciation and amortization expense of property and equipment was $0.9 million and $1.5 million for the three and six months ended June 30, 2023, respectively. Depreciation and amortization expense of property and equipment was $0.5 million and $1.1 million for the three and six months ended June 30, 2022, respectively.

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Note 3. Commitments and Contingencies

Operating Leases

In August 2014, the Company entered into a five-year operating lease for approximately 12,215 square feet of office space beginning on November 1, 2014, and expiring on October 31, 2019. In June 2019, the lease was amended to extend the expiration date to October 31, 2020. In September 2020, the lease was amended to extend the expiration date to July 31, 2022. In December 2021, the lease was amended to extend the expiration date to January 31, 2028, and in April 2023, the lease was amended to reduce the expiration date to March 31, 2024. Upon the execution of the amendments, which were deemed to be a lease modification, the Company reassessed the lease liability using the incremental borrowing rate for a collateralized asset of the same remaining term at the modification date and adjusted the carrying amount of ROU assets by the amount of the remeasurement of the liability. The Company also reassessed the lease classification and concluded that the lease continues to be an operating lease. Under the terms of the lease, the Company is responsible for taxes, insurance, and maintenance expense. The lease contains certain scheduled rent increases. Rent expense is recognized on a straight-line basis over the expected lease term.

The Company entered into an operating lease for approximately 25,548 square feet of office space beginning on August 1, 2018, and expiring on October 31, 2027. In April 2023, the lease was amended to reduce the expiration date to December 31, 2024. Upon the execution of the amendment, which was deemed to be a lease modification, the Company reassessed the lease liability using the incremental borrowing rate for a collateralized asset of the same remaining term at the modification date and adjusted the carrying amount of ROU assets by the amount of the remeasurement of the liability. The Company also reassessed the lease classification and concluded that the lease continues to be an operating lease. Under the terms of the lease, the Company is responsible for taxes, insurance, and maintenance expense. The lease contains certain scheduled rent increases. Rent expense is recognized on a straight-line basis over the expected lease term. The Company has a renewal option to extend the term of the lease for a period of five years beyond the initial term. Under the terms of the lease, the base rent payable with respect to each renewal term will be equal to the prevailing market rental rent as of the commencement of the applicable renewal term. In the event of a default of certain of the Company’s obligations under the lease, the Company’s landlord would have the right to terminate the lease.

In June 2019, the Company entered into an eight-year operating lease for approximately 32,621 square feet of office space beginning on January 15, 2020 and expiring on January 31, 2028. In April 2023, the lease was amended to reduce the expiration date to March 31, 2024. Upon the execution of the amendment, which was deemed to be a lease modification, the Company reassessed the lease liability using the incremental borrowing rate for a collateralized asset of the same remaining term at the modification date and adjusted the carrying amount of ROU assets by the amount of the remeasurement of the liability. The Company also reassessed the lease classification and concluded that the lease continues to be an operating lease. The Company uses these premises as its new principal executive offices and for general office space. The Company is utilizing its other currently-leased spaces to conduct the training of its sales team and for manufacturing purposes. Under the terms of the lease, the Company is responsible for taxes, insurance, and maintenance expense. The lease contains certain scheduled rent increases. Rent expense is recognized on a straight-line basis over the expected lease term. The Company has a renewal option to extend the term of the lease for a period of five years beyond the initial term. Under the terms of the lease, the base rent payable with respect to each renewal term will be equal to the prevailing market rental rent as of the commencement of the applicable renewal term. In the event of a default of certain of the Company’s obligations under the lease, the Company’s landlord would have the right to terminate the lease.

In August 2020, the Company entered into a 38-month operating lease for approximately 5,693 square feet of warehouse space beginning on October 15, 2020 and expiring on December 31, 2023. In April 2023, the lease was amended to extend the expiration date to December 31, 2024. Upon the execution of the amendment, which was deemed to be a lease modification, the Company reassessed the lease liability using the incremental borrowing rate for a collateralized asset of the same remaining term at the modification date and adjusted the carrying amount of ROU assets by the amount of the remeasurement of the liability. The Company also reassessed the lease classification and concluded that the lease continues to be an operating lease. The Company uses these premises for general warehouse space.

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In March 2022, the Company entered into an 18-month operating lease for approximately 3,276 square feet of warehouse space beginning on July 1, 2022 and expiring on December 31, 2023. In April 2023, the lease was amended to extend the expiration date to December 31, 2024. Upon the execution of the amendment, which was deemed to be a lease modification, the Company reassessed the lease liability using the incremental borrowing rate for a collateralized asset of the same remaining term at the modification date and adjusted the carrying amount of ROU assets by the amount of the remeasurement of the liability. The Company also reassessed the lease classification and concluded that the lease continues to be an operating lease. The Company uses these premises for general warehouse space.

In April 2023, the Company entered into a 120-month operating lease for approximately 145,960 square feet of office and warehouse space beginning on April 1, 2024 and expiring on March 31, 2034. The Company will use these premises as its new principal executive offices and for general office, manufacturing, and warehousing space. Under the terms of the lease, the Company is responsible for taxes, insurance, and maintenance expense. The lease contains certain scheduled rent increases. Rent expense is recognized on a straight-line basis over the expected lease term. The Company has a renewal option to extend the term of the lease for a period of five years beyond the initial term. Under the terms of the lease, the base rent payable with respect to each renewal term will be equal to the prevailing market rental rent as of the commencement of the applicable renewal term. In the event of a default of certain of the Company’s obligations under the lease, the Company’s landlord would have the right to terminate the lease. The Company has not taken possession or has been given control of this leased property as of June 30, 2023. Therefore, the Company has not recorded any ROU assets or operating lease liabilities related to this lease.

During the three and six months ended June 30, 2023, there were no ROU assets obtained in exchange for new operating lease liabilities. During the three and six months ended June 30, 2022, there were no ROU assets obtained in exchange for new operating lease liabilities. As of June 30, 2023 and December 31, 2022, the ROU assets had a balance of $0.7 million and $6.2 million, respectively. The operating lease ROU assets are included within the Company’s non-current other assets, and lease liabilities are included in current or noncurrent liabilities in the Company’s unaudited condensed consolidated balance sheets. During the three and six months ended June 30, 2023, cash paid for amounts included in operating lease liabilities was $0.5 million and $1.0 million, respectively. During the three and six months ended June 30, 2022, cash paid for amounts included in operating lease liabilities was $0.5 million and $1.0 million, respectively. Amortization of the ROU assets was $0.1 million and $0.4 million for the three and six months ended June 30, 2023, respectively. Amortization of the ROU assets was $0.3 million and $0.5 million for the three and six months ended June 30, 2022, respectively.

As of June 30, 2023 and December 31, 2022, the weighted-average remaining lease term for the Company’s operating leases was 1.2 years and 4.9 years, respectively. The weighted-average incremental borrowing rate for a collateralized asset of the same remaining term used to determine the present value of the Company’s operating leases’ future payments was 5.9% and 7.1%, respectively.

Total lease costs for the three and six months ended June 30, 2023 and 2022 are as follows (in thousands):

	Three Months Ended June 30,				Six Months Ended June 30,
	2023		2022		2023		2022
Lease cost
Operating lease cost	$	546	$	524	$	1,088	$	1,048
Short-term lease cost	22		20		45		41
Variable lease cost	178		132		285		257
Amortization of net lease liabilities	(656)		(94)		(723)		(184)
Total lease cost	$	90	$	582	$	695	$	1,162

License Agreement

In October 2013, the Company entered into the License Agreement, pursuant to which AMF, a Company stockholder, licensed the Company certain patents and know-how (collectively, the AMF IP) relating to, in relevant part, an implantable pulse generator and related system components in development by AMF as of that date, in

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addition to any peripheral or auxiliary devices, including all components, that when assembled, comprise such device, excluding certain implantable pulse generators (collectively, the AMF Licensed Products). Under the License Agreement, for each calendar year beginning in 2018, the Company is obligated to pay AMF a royalty on an AMF Licensed Product-by-AMF Licensed Product basis if one of the following conditions applies: (i) one or more valid claims within any of the patents licensed to the Company by AMF covers such AMF Licensed Products or the manufacture of such AMF Licensed Products or (ii) for a period of 12 years from the first commercial sale anywhere in the world of such AMF Licensed Product, in each case. The foregoing royalty is calculated as the greater of (a) 4% of all net revenue derived from the AMF Licensed Products, and (b) the Minimum Royalty, payable quarterly. The Minimum Royalty automatically increases each year after 2018, subject to a maximum amount of $200,000 per year. The Company recorded related royalties of $0.8 million and $1.1 million during the three and six months ended June 30, 2023, respectively. The Company recorded related royalties of $0.6 million and $2.2 million during the three and six months ended June 30, 2022, respectively. Royalty expense is included in operating expenses in the unaudited condensed consolidated statements of comprehensive loss. Accrued royalties of $0.7 million and $0.6 million as of June 30, 2023 and December 31, 2022, respectively, are included within accrued liabilities in the Company’s unaudited condensed consolidated balance sheets. Royalty expense is declining because the Company’s F15 recharge-free SNM device is not covered by any AMF patents licensed to the Company and is therefore not an AMF Licensed Product that requires the payment of a royalty to AMF.

Legal Matters

The Company may, from time to time, become a party to legal proceedings. Such matters are subject to many uncertainties and to outcomes of which the financial impacts are not predictable with assurance and that may not be known for extended periods of time. When management has assessed that a loss is probable and an amount can be reasonably estimated, the Company records a liability.

On November 4, 2019, Medtronic, Inc., Medtronic Puerto Rico Operations Co., Medtronic Logistics LLC and Medtronic USA, Inc. (collectively, the Medtronic Affiliates) filed a complaint against the Company in the U.S. District Court for the Central District of California, Case No. 8:19-cv-2115, and amended the complaint on November 26, 2019. The Company refers to this matter as the Medtronic Litigation. The complaint asserts that the Company’s rechargeable SNM system infringes U.S. Patent Nos. 8,036,756, 8,626,314, 9,463,324 and 9,821,112 held by the Medtronic Affiliates, and the amended complaint further includes the additional patents 8,738,148; 8,457,758; and 7,774,069 (collectively, the Medtronic Patents). The Medtronic Litigation requests customary remedies for patent infringement, including (i) a judgment that the Company has infringed and is infringing the Medtronic Patents, (ii) damages, including treble damages for willful infringement, (iii) a permanent injunction preventing the Company from infringing the Medtronic Patents, (iv) attorneys’ fees, and (v) costs and expenses. The Company believes the allegations are without merit and is vigorously defending itself against them. The Company is unable to predict the likelihood of success of the claims of the Medtronic Affiliates against the Company or to quantify any risk of loss. The Medtronic Litigation could last for an extended period of time and require the Company to dedicate significant financial resources and management resources to its defense. An adverse ruling against the Company could materially and adversely affect its business, financial position, results of operations or cash flows and could also result in reputational harm. Even if the Company is successful in defending against these claims, the Medtronic Litigation could result in significant costs, delays in future product developments, reputational harm or other collateral consequences. The Federal Circuit recently reversed the decision of the Patent Trials & Appeals Board of the U.S. Patent & Trademark Office (PTAB) that the tined leads patents asserted against Axonics were valid, finding that the PTAB committed legal error in its analysis. The Federal Circuit remanded the matter to the PTAB for another review consistent with its opinion. Because of this development, the Court has issued a stay on the litigation proceedings, pending the outcome of the proceedings before the PTAB. As a result, the jury trial previously scheduled for August 2023 has been postponed.

AMF has alleged that the Company is in material breach of the License Agreement because it is not paying royalties on its F15 product, and AMF has claimed that it has terminated the License Agreement on that basis. The Company strongly disagrees that it is required to pay royalties on F15 or that AMF has the right to terminate the License Agreement. The Company has paid and will continue to pay 4% royalties on the rechargeable products launched to date. If the dispute between the parties cannot be settled amicably, the parties are obligated to go to arbitration. While a loss related to this claim is possible, the Company does not believe such loss is probable or estimable at this time.

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In addition to the matters described above, the Company is and may continue to be involved in claims, legal proceedings, and investigations arising out of its operations in the normal course of business.

Note 4. Stock-Based Compensation

Stock-based compensation expense included in the Company’s unaudited condensed consolidated statements of comprehensive loss is allocated as follows (in thousands):

	Three Months Ended June 30,				Six Months Ended June 30,
	2023		2022		2023		2022
Research and development	$	2,414	$	1,752	$	4,618	$	3,262
General and administrative	3,059		1,991		5,885		3,928
Sales and marketing	5,731		4,162		11,415		7,853
	$	11,204	$	7,905	$	21,918	$	15,043

Stock Option Activity

The option awards issued under the 2014 Stock Option Plan (the 2014 Plan) and the 2018 Omnibus Incentive Plan (the 2018 Plan) were measured based on fair value. The Company used the simplified method of determining the expected term of stock options as the Company believes this represents the best estimate of the expected term of a new option. The expected stock price volatility assumption was determined by examining the historical volatilities for industry peers, as the Company did not have sufficient trading history for the Company’s common stock. The Company will continue to analyze the historical stock price volatility and expected term assumption as more historical data for the Company’s common stock becomes available. The risk-free interest rate assumption is based on the U.S. Treasury instruments, whose term was consistent with the expected term of the Company’s stock options. The expected dividend assumption is based on the Company’s history and expectation of dividend payouts. The assumptions regarding the expected term of the options and the expected volatility of the stock price are subjective, and these assumptions have a significant effect on the estimated fair value amounts. There were no stock option grants for the three and six months ended June 30, 2023 and 2022.

As of June 30, 2023 and December 31, 2022, there was $0.7 million and $1.8 million, respectively, of total unrecognized compensation cost related to unvested stock options that is expected to be recognized over a weighted-average period of approximately 0.8 years and 1.0 year, respectively.

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The following table summarizes stock option activity for the six months ended June 30, 2023 under the 2014 and 2018 Plans (in thousands, except share and per share data):

	Number of Options	Weighted-Average Exercise Price Per Share		Aggregate Intrinsic Value
Outstanding at December 31, 2022	1,046,610	$	18.81
Options exercised	(159,681)	17.50		$	6,978	(1)
Options forfeited	(585)	29.71
Outstanding at June 30, 2023	886,344	$	19.03	$	28,118	(2)

_____________________________________________

(1)    Represents the total difference between the Company’s closing stock price at the time of exercise and the stock option exercise price, multiplied by the number of options exercised.

(2)    Represents the total difference between the Company’s closing stock price on the last trading day of the second quarter of 2023 and the stock option exercise price, multiplied by the number of in-the-money options as of June 30, 2023. The amount of intrinsic value will change based on the fair market value of the Company’s stock.

The weighted-average remaining contractual term of options outstanding and exercisable was 5.7 years and 6.1 years at June 30, 2023 and December 31, 2022, respectively.

Restricted Shares Awards Activity

As of June 30, 2023 and December 31, 2022, there was $56.8 million and $54.0 million, respectively, of total unrecognized compensation cost related to unvested restricted shares awards that is expected to be recognized over a weighted-average period of approximately 2.1 years and 2.3 years, respectively.

The following table summarizes restricted shares awards activity for the six months ended June 30, 2023:

	Number of Restricted Shares Awards	Weighted-Average Fair Value Per Share at Grant Date
Outstanding at December 31, 2022	1,320,866	$	52.23
Restricted shares awards granted	349,866	57.11
Restricted shares awards vested	(342,907)	43.28
Restricted shares awards forfeited	(59,518)	55.23
Outstanding at June 30, 2023	1,268,307	$	55.86

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Restricted Stock Units Activity

As of June 30, 2023 and December 31, 2022, there was $11.4 million and $1.3 million, respectively, of total unrecognized compensation cost related to unvested restricted stock units that is expected to be recognized over a weighted-average period of approximately 1.0 year and 0.8 years, respectively.

The following table summarizes restricted stock units activity for the six months ended June 30, 2023:

	Number of Restricted Stock Units	Weighted-Average Fair Value Per Share at Grant Date
Outstanding at December 31, 2022	183,418	$	48.74
Restricted stock units granted	286,750	65.44
Restricted stock units vested	(199,718)	49.84
Outstanding at June 30, 2023	270,450	$	70.10

Note 5. Income Taxes

The following table presents details of the provision for income taxes and effective tax rates (in thousands, except percentages):

	Three Months Ended June 30,		Six Months Ended June 30,
	2023	2022	2023	2022
Income tax benefit	$(304)	$(465)	$(1,111)	$(1,576)
Effective tax rate	3.97%	2.13%	6.27%	3.45%

The Company accounts for income taxes according to ASC 740, “Income Taxes.” The Company periodically evaluates whether a portion or all of its deferred tax assets will be recovered. The Company records a valuation allowance against deferred tax assets if and to the extent it is more likely than not that they will not be recovered. In evaluating the need for a valuation allowance, the Company weighs all relevant positive and negative evidence, including among other factors, historical financial performance, forecasts of income over the applicable carryforward periods, and the market environment, with each consideration weighted based on its reliability. The Company continues to maintain a full valuation allowance against its otherwise recognizable U.S. net deferred income tax assets as of June 30, 2023 and December 31, 2022.

The effective tax rate differs from the statutory U.S. income tax rate due to differing tax rates imposed on income earned in foreign jurisdictions, losses in foreign jurisdictions, and certain nondeductible expenses. The effective tax rate could change significantly from quarter to quarter because of recurring and nonrecurring factors. The provision for income taxes for the six months ended June 30, 2023 was primarily the result of losses benefited in certain foreign jurisdictions.

At December 31, 2022, the Company had U.S. federal and foreign net operating loss (NOL) carryforwards of approximately $270.3 million and $9.6 million, respectively. U.S. federal NOLs in the amount of $51.5 million will expire between 2033 and 2037 while the remainder will carryover indefinitely. The foreign net operating loss carryforwards have an indefinite carryforward period. The Company had U.S. state NOLs of $254.6 million, which will expire between 2033 and 2042. Interest and penalties related to income tax matters are recorded in income tax expense (benefit) in the condensed consolidated statements of comprehensive loss and the related liability is recorded in accrued liabilities in the condensed consolidated balance sheets, as applicable.

Pursuant to Sections 382 and 383 of the Internal Revenue Code of 1986, as amended (the Internal Revenue Code), use of the Company’s NOL carryforwards may be limited if the Company experiences a cumulative change in ownership of greater than 50% in a rolling three-year period. The Company performed an analysis of changes in ownership for purposes of these Internal Revenue Code sections. Based on the study performed in 2020, the

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Company determined that an ownership change occurred in 2014, 2018 and 2019. The total reduction of the net operating loss carryforwards was offset by valuation allowance, and there was no impact to tax expense related to the limitation. Based on the study performed in 2022 and 2021, the Company determined that an ownership change did not occur in 2022 and 2021. Future ownership changes could impact the Company’s ability to utilize NOL carryforwards.

Note 6. Employee Benefit Plan

The Company sponsors a defined contribution retirement savings plan under Section 401(k) of the Internal Revenue Code. This plan covers all U.S. employees who meet minimum age and service requirements, and allows participants to defer a portion of their annual compensation on a pre- or post-tax basis. Contributions to the plan by the Company may be made at the discretion of the board of directors. During the three and six months ended June 30, 2023, the Company contributions to the plan amounted to $0.6 million and $1.2 million, respectively. During the three and six months ended June 30, 2022, the Company contributions to the plan amounted to $0.5 million and $1.0 million, respectively.

Note 7. Goodwill and Intangible Assets

The change in the carrying amount of goodwill during the six months ended June 30, 2023 included the following (in thousands):

December 31, 2022	$	94,414
Foreign currency translation adjustment	4,466
June 30, 2023	$	98,880

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Intangible assets as of June 30, 2023 included the following (in thousands):

		June 30, 2023
	Weighted-Average Amortization Period	Gross Carrying Amount		Accumulated Amortization		Impairment		Foreign currency translation adjustment		Intangible Assets, Net
Patent license asset	8.71 years	$	1,000	$	(1,000)	$	—	$	—	$	—
Exclusive license asset	4 years	3,300		(1,980)		—		—		1,320
Technology	12 years	81,100		(15,863)		—		(6,380)		58,857
Trade names and trademarks	Indefinite	19,700		—		—		(1,580)		18,120
Customer relationships	12 years	11,400		(3,087)		(287)		(780)		7,246
		$	116,500	$	(21,930)	$	(287)	$	(8,740)	$	85,543

Intangible assets as of December 31, 2022 included the following (in thousands):

		December 31, 2022
	Weighted-Average Amortization Period	Gross Carrying Amount		Accumulated Amortization		Impairment		Foreign currency translation adjustment		Intangible Asset, Net
Patent license asset	8.71 years	$	1,000	$	(1,000)	$	—	$	—	$	—
Exclusive license asset	4 years	3,300		(1,540)		—		—		1,760
Technology	12 years	81,100		(12,496)		—		(9,141)		59,463
Trade names and trademarks	Indefinite	19,700		—		—		(2,398)		17,302
Customer relationships	12 years	11,400		(2,393)		(287)		(992)		7,728
		$	116,500	$	(17,429)	$	(287)	$	(12,531)	$	86,253

Item 2.    Management’s Discussion and Analysis of Financial Condition and Results of Operations.

The following discussion and analysis should be read in conjunction with our unaudited condensed consolidated financial statements and the related notes to those statements included elsewhere in this Quarterly Report on Form 10-Q, as well as the audited consolidated financial statements and the related notes thereto, and the discussion under “Management’s Discussion and Analysis of Financial Condition and Results of Operations” and “Business” included in our Annual Report on Form 10-K for the fiscal year ended December 31, 2022, as filed with the SEC on March 1, 2023.

Overview

We are a global medical technology company that is developing and commercializing novel products for adults with bladder and bowel dysfunction, including: (i) implantable rechargeable sacral neuromodulation (SNM) systems to treat urinary urge incontinence (UUI) and urinary urgency frequency (UUF), together referred to as overactive bladder (OAB), as well as fecal incontinence (FI), and non-obstructive urinary retention (UR); and (ii) a urethral bulking agent to treat female stress urinary incontinence (SUI).

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SNM Systems

Our newly developed rechargeable SNM system, Axonics R20, is designed to last 20 or more years in the human body and is only 5cc in volume. R20 provides constant current stimulation and offers broad MRI access with 1.5T and 3.0T scanners. R20 utilizes an easy-to-use, intuitive patient remote control and requires recharging for only one hour every 6 to 10 months, which is the longest interval between recharging among rechargeable SNM systems. The R20 received FDA approval in January 2023 and replaces the previous rechargeable SNM system offered by Axonics that was the first to be marketed worldwide.

Our recharge-free SNM system, Axonics F15, received FDA approval in March 2022 and utilizes a primary cell battery with an expected life of 15 years at typical stimulation parameters and over 20 years at lower amplitude settings. The recharge-free implantable neurostimulator (INS) is approximately 10cc in volume, utilizes constant current stimulation, a recharge-free patient remote control and offers broad MRI access.

We began U.S. commercialization in the middle of the fourth quarter of 2019 after receiving premarket approval (PMA) of our first rechargeable SNM system by the FDA. We also have marketing approvals from regulators in Europe, Canada, and Australia for all relevant clinical indications.

SNM therapy has been commercially available in the United States for over 20 years and has been clinically proven to provide a safe, effective, reversible, and long-lasting symptom relief. We believe that our SNM systems offer therapeutic benefits and competitive advantages compared to the InterStim SNM systems offered by Medtronic.

We engineered our SNM systems to deliver constant-current stimulation, which automatically adjusts stimulation based on changes to impedance that occur as the implanted lead scars into the body, which we believe provides a more consistent therapy over time and reduces management of the therapy. Our SNM systems include an easy-to-use wireless patient remote control that does not require recharging or replacement batteries. We also designed and custom built a clinician programmer that guides the implanting physician through lead placement and stimulation programming.

We focus most of our sales and marketing efforts in the United States where reimbursement for SNM therapy is well-established and covered by most major U.S. insurers and Medicare.

Urethral Bulking Agent

On February 25, 2021, we acquired Contura Limited (Contura) and its Bulkamid product, a urethral bulking hydrogel indicated for the treatment of female SUI.

SUI is a common condition that afflicts women of all ages, with childbirth as one of the main contributing factors. SUI is caused by weakness in the pelvic floor, preventing the urethra from closing fully when sudden pressure is put on the bladder. This can allow urine to leak out during normal daily activities such as coughing, laughing, exercising, or lifting an object.

Bulkamid received a Conformité Européenne (CE) Mark in 2003 and a PMA from the FDA in 2020 and is sold through a combination of a direct sales force in the United States, Germany, United Kingdom, and the Nordic countries and distributors in certain international markets.

As a next-generation bulking agent, we believe Bulkamid addresses the shortcomings of legacy particulate-based bulking agents. It is a unique and patented non-particulate hydrogel that is injected into the urethral wall to restore the natural closing pressure of the urethra. It is a simple, quick, and easy-to-learn and perform procedure that can be performed in either a physician’s office or an outpatient facility.

Bulkamid is biocompatible, consisting of 97.5% water, and does not induce a chronic inflammatory response. Bulkamid’s bulking effect is aided by the volume of each injection being predictable, controllable, and precise. Bulkamid retains its bulking characteristics for a number of years, thereby maintaining efficacy and providing women with long lasting relief of their SUI symptoms. Bulkamid is clinically validated and generates high rates of patient satisfaction.

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Our Markets

The market for SNM therapy is large and growing, with approximately 19 million women in the United States having moderate to severe UUI or mixed urinary incontinence (MUI) symptoms, which is urinary incontinence related to both urgency and stress. Before treating patients with a third-line therapy such as SNM, physicians are required to prescribe first- and second-line therapies. First-line therapies include behavioral changes such as diet and exercise, and second-line therapies include drug therapy. We believe the SNM market will continue to expand for the foreseeable future driven by increased awareness and education of SNM therapy, greater expectations for quality of life, and improved patient attitudes toward receiving medical attention. In addition, market growth is anticipated due to continued innovation and the introduction of new efficacious and long-lived products for SNM therapy. We believe that this represents a compelling opportunity for our SNM systems to capture market share and grow the market for SNM therapy.

The market for SUI therapy is highly underpenetrated, with approximately 22 million women in the United States having moderate to severe SUI or MUI symptoms. The first-line treatment options for SUI begin with lifestyle changes and continence pessaries. SUI lacks pharmacologic treatments, with patients next advancing to urethral bulking agents, pelvic floor sling surgery or colposuspension. We estimate that less than half of these women have sought medical treatment, most of whom were offered conservative therapy or opted for no treatment due to a lack of non-invasive treatment options with high efficacy.

While we anticipate expanding into other geographic regions over time, we are primarily focusing on marketing our products in the United States and Europe due to the large overall market size.

In the United States, the cost required to treat each patient is reimbursed through various third-party payors, such as commercial payors and government agencies. Most large insurers have established coverage policies in place to cover SNM therapy. Certain commercial payors have a patient-by-patient prior authorization process that must be followed before they will provide reimbursement for SNM therapy. Outside the United States, reimbursement levels vary significantly by country and by region, particularly based on whether the country or region at issue maintains a single-payor system. SNM therapy is eligible for reimbursement in Canada, Australia and certain countries in Europe. Annual healthcare budgets generally determine the number of SNM systems that will be paid for by the payor in these single-payor system countries and regions. Reimbursement is obtained from a variety of sources, including government-sponsored and private health insurance plans, and combinations of both. Some countries or regions may require us to gather additional clinical data before granting coverage and reimbursement for our SNM systems.

We are currently engaged in the manufacturing of a number of processes of our SNM systems and outsource the manufacture of certain implantable components of our SNM systems with contract manufacturers who all have quality systems established that meet FDA requirements and are all recognized in their field for their competency to manufacture the respective portions of our SNM systems. We believe the manufacturers we currently utilize have sufficient capacity to meet our requirements and are able to scale up their capacity relatively quickly with limited capital investment.

Prior to obtaining our initial FDA approval, we devoted substantially all of our resources to research and development activities related to our rechargeable SNM system, including clinical and regulatory initiatives to obtain marketing approvals. We spend a significant amount of our resources on sales and marketing activities to commercialize and market our line of SNM systems in the United States.

We incurred net losses of $16.6 million and $44.1 million for the six months ended June 30, 2023 and 2022, respectively, and had an accumulated deficit of $390.9 million as of June 30, 2023 compared to $374.3 million at December 31, 2022. As of June 30, 2023, we had available cash, cash equivalents, and short-term investments of approximately $331.5 million, current liabilities of approximately $32.1 million, and long-term liabilities of approximately $16.4 million.

August 2022 Follow-On Offering

On August 5, 2022, we completed a follow-on offering by issuing 2,012,500 shares of common stock, at an offering price of $63.85 per share. The gross proceeds to us from this follow-on offering were $128.5 million and the net proceeds were approximately $128.3 million, after deducting offering expenses payable by us.

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Components of Our Results of Operations

Net Revenue

Revenue during the three and six months ended June 30, 2023 and 2022 are as follows (in thousands):

	Three Months Ended June 30,				Six Months Ended June 30,
	2023		2022		2023		2022
SNM net revenue
United States	$	72,205	$	54,468	$	126,058	$	92,183
International markets	1,983		1,290		3,288		2,645
	$	74,188	$	55,758	$	129,346	$	94,828
Bulkamid net revenue
United States	$	14,806	$	10,223	$	26,419	$	16,792
International markets	3,900		2,999		7,779		5,780
	$	18,706	$	13,222	$	34,198	$	22,572
Total net revenue	$	92,894	$	68,980	$	163,544	$	117,400

We expect our revenue to fluctuate from quarter to quarter due to a variety of factors, including seasonality. For example, the industry generally experiences lower revenues in the first and third quarters of the year and higher revenues in the fourth quarter. Our revenue has been impacted by these industry trends.

Cost of Goods Sold and Gross Margin

Cost of goods sold consists primarily of costs of the components of our SNM systems, third-party contract labor costs, overhead costs, Bulkamid product costs, as well as distribution-related expenses such as logistics and shipping costs. The overhead costs include the cost of material procurement and operations supervision and management personnel. We expect overhead costs as a percentage of net revenue to decrease as our sales volume increases. Cost of goods sold also include other expenses such as scrap and inventory obsolescence. We expect cost of goods sold to increase in absolute dollars primarily as, and to the extent, our net revenue grows. We expect gross margin to vary based on manufacturing costs, regional differences in pricing, and discounts negotiated by customers.

We calculate gross margin as gross profit divided by net revenue. We expect future gross margin will be affected by a variety of factors, including manufacturing costs, the average selling price of our products, the implementation of cost-reduction strategies, inventory obsolescence costs, which may occur when new generations of our SNM systems are introduced, and to a lesser extent, the sales mix between the United States and international markets as our average selling price in the United States is expected to be higher than in international markets and foreign currency exchange rates. Our gross margin may increase over the long term to the extent our production volumes increase and we receive discounts on the costs charged by our contract manufacturers, thereby reducing our per unit costs. Additionally, our gross margin may fluctuate from quarter to quarter as we continue to introduce new products and adopt new manufacturing processes and technologies.

Research and Development Expenses

Research and development expenses consist primarily of employee compensation, including stock-based compensation, product development, including testing and engineering, royalty expense, and clinical studies to develop and support our SNM systems, including clinical study and registry management and monitoring, payments to clinical investigators, and data management. Other research and development expenses include consulting and advisory fees, royalty expense, travel expenses, and equipment-related expenses and other miscellaneous office and facilities expenses related to research and development programs. Research and development costs are expensed as incurred. We expect to continue incurring research and development expenses in the future as we develop new products and expand to new markets. We expect research and development expenses as a percentage of net revenue to vary over time depending on the level and timing of initiating new product development efforts and new clinical development activities.

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The following table summarizes our research and development expenses by functional area for the three and six months ended June 30, 2023 and 2022 (in thousands):

	Three Months Ended June 30,				Six Months Ended June 30,
	2023		2022		2023		2022
Personnel related	$	5,783	$	4,022	$	11,389	$	9,159
Clinical development	243		270		377		538
Contract R&D and manufacturing	1,759		1,936		3,486		5,892
Royalty expense	785		680		1,092		2,235
Other R&D expenses	379		227		661		547
Total R&D expenses	$	8,949	$	7,135	$	17,005	$	18,371

General and Administrative Expenses

General and administrative expenses consist primarily of employee compensation, including stock-based compensation, and spending related to finance, information technology, human resource functions, consulting, legal, and professional service fees. Other general and administrative expenses include director and officer insurance premiums, investor relations costs, office-related expenses, facilities and equipment rentals, bad debt expense, travel expenses, and impairment expenses. We expect our general and administrative expenses will significantly increase in absolute dollars as we increase our headcount and expand administrative personnel to support our growth and operations. Additionally, we anticipate increased legal expenses associated with our patent infringement litigation with Medtronic. We expect general and administrative expenses to decrease as a percentage of net revenue primarily as, and to the extent, our net revenue grows.

Sales and Marketing Expenses

Sales and marketing expenses consist primarily of employee compensation, including sales personnel commissions and stock-based compensation, direct-to-consumer advertising programs, trade shows, booth exhibition costs, and the related travel for these events. Other sales and marketing expenses include consulting and advisory fees. We expect sales and marketing expenses to continue to increase in absolute dollars as we continue to expand our commercial infrastructure to both drive and support our expected growth in net revenue. However, we expect sales and marketing expenses to decrease as a percentage of net revenue in the long term primarily as, and to the extent, our net revenue grows.

Amortization of Intangible Assets

Amortization of intangible assets consist primarily of amortization expense on patent license asset, manufacturing license asset, technology, and customer relationships intangible assets. We amortize finite lived intangible assets over the period of estimated benefit using the straight-line method.

Acquisition-Related Costs

Acquisition-related costs consist of expenses incurred and changes in contingent consideration related to the Contura acquisition.

Acquired In-Process Research & Development

Acquired in-process research & development consist of expenses incurred related to the Radian acquisition.

Other Income (Expense), Net

Other income (expense), net consists primarily of interest and accretion income earned on cash equivalents and short-term investments, gains and losses on foreign currency transactions, net of interest expense payable under the Loan and Security Agreement with Silicon Valley Bank and other debt arrangements.

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Income Tax Expense (Benefit)

Income tax expense (benefit) primarily consists of losses benefited in certain foreign jurisdictions. We maintain a full valuation allowance for deferred tax assets in our domestic operations, including net operating loss carryforwards and research and development credits.

Results of Operations

The following table shows our results of operations for the six months ended June 30, 2023 and 2022 (in thousands, except percentages):

	Three Months Ended June 30,						Period to Period Change		Six Months Ended June 30,						Period to Period Change
	2023			2022					2023			2022
Net revenue	$	92,894		$	68,980		$	23,914	$	163,544		$	117,400		$	46,144
Cost of goods sold	22,704			18,784			3,920		40,854			33,962			6,892
Gross profit	70,190			50,196			19,994		122,690			83,438			39,252
Gross Margin	75.6		%	72.8		%			75.0		%	71.1		%
Operating expenses
Research and development	8,949			7,135			1,814		17,005			18,371			(1,366)
General and administrative	10,713			10,572			141		22,881			20,585			2,296
Sales and marketing	44,270			39,381			4,889		86,924			72,444			14,480
Amortization of intangible assets	2,279			2,332			(53)		4,501			4,795			(294)
Acquisition-related costs	602			12,205			(11,603)		2,368			12,205			(9,837)
Acquired in-process research & development	15,447			—			15,447		15,447			—			15,447
Total operating expenses	82,260			71,625			10,635		149,126			128,400			20,726
Loss from operations	(12,070)			(21,429)			9,359		(26,436)			(44,962)			18,526
Other income (expense)
Interest and other income	4,250			360			3,890		7,878			403			7,475
Interest and other expense	174			(839)			1,013		857			(1,128)			1,985
Other income (expense), net	4,424			(479)			4,903		8,735			(725)			9,460
Loss before income tax benefit	(7,646)			(21,908)			14,262		(17,701)			(45,687)			27,986
Income tax benefit	(304)			(465)			161		(1,111)			(1,576)			465
Net loss	(7,342)			(21,443)			14,101		(16,590)			(44,111)			27,521
Foreign currency translation adjustment	3,750			(12,648)			16,398		6,821			(17,568)			24,389
Comprehensive loss	$	(3,592)		$	(34,091)		$	30,499	$	(9,769)		$	(61,679)		$	51,910

Comparison of the Three Months Ended June 30, 2023 and 2022

Net Revenue

Net revenue was $92.9 million for the three months ended June 30, 2023, an increase of $23.9 million, or 34.7%, compared to $69.0 million for the three months ended June 30, 2022. Net revenue is primarily derived from the sale of our products to customers in the United States and certain international markets. The increase in net revenue is primarily due to increased sales of our products as we expanded our customer base in the U.S. and increased sales with our existing customer base. Our expanded product offering of the fourth-generation rechargeable SNM system in January 2023, recharge-free SNM system in March 2022 and the acquisition of the Bulkamid product in February 2021 have also contributed to our expansion of customers and more patients being treated with our existing customers.

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Cost of Goods Sold and Gross Margin

We incurred $22.7 million of cost of goods sold for the three months ended June 30, 2023. We incurred $18.8 million of cost of goods sold for the three months ended June 30, 2022. Gross margin was 75.6% in the three months ended June 30, 2023, compared to 72.8% for the three months ended June 30, 2022. The increase in gross margin is primarily due to higher sales volumes and product mix.

Research and Development Expenses

Research and development expenses increased $1.8 million, or 25.4%, to $8.9 million in the three months ended June 30, 2023, compared to $7.1 million in the three months ended June 30, 2022. The increase in research and development expenses was primarily attributable to an increase of $2.0 million in personnel costs including salaries and wages, stock-based compensation and other employee-related benefits, partially offset by a decrease of $0.4 million in contract R&D and manufacturing costs.

General and Administrative Expenses

General and administrative expenses increased $0.1 million, or 1.3%, to $10.7 million in the three months ended June 30, 2023, compared to $10.6 million in the three months ended June 30, 2022, primarily as a result of an increase of $0.9 million in personnel costs including salaries and wages, stock-based compensation and other employee-related benefits, partially offset by a decrease of $0.5 million in facility related expenses and a decrease of $0.3 million in legal fees.

Sales and Marketing Expenses

Sales and marketing expenses increased $4.9 million, or 12.4%, to $44.3 million in the three months ended June 30, 2023, compared to $39.4 million in the three months ended June 30, 2022. The increase in sales and marketing expenses was primarily as a result of an increase of $6.3 million related to personnel costs including salaries, wages, sales personnel commissions, stock-based compensation and other employee-related benefits, partially offset by a decrease of $2.2 million related to advertising expenses.

Amortization of Intangible Assets

Amortization of intangible assets was $2.3 million in the three months ended June 30, 2023, compared to $2.3 million in the three months ended June 30, 2022. Amortization of intangible assets consisted primarily of technology and customer relationships acquired related to the Contura acquisition.

Acquisition-Related Costs

Acquisition-related costs were $0.6 million and $12.2 million in the three months ended June 30, 2023 and 2022, respectively, which related to the change in fair value of contingent consideration.

Acquired In-Process Research & Development

Acquired in-process research & development was $15.4 million for the three months ended June 30, 2023 which related to the Radian acquisition. We recorded no acquired in-process research & development in the three months ended June 30, 2022.

Other Income (Expense), Net

Other income, net was $4.4 million in the three months ended June 30, 2023 consisting primarily of interest income on cash equivalents and short-term investments. Other expense, net was $0.5 million in the three months ended June 30, 2022 consisting primarily of losses on foreign currency transactions, partially offset by interest income on cash equivalents and short-term investments.

Income Tax Benefit

Income tax benefit was $0.3 million for the three months ended June 30, 2023 primarily related to losses in certain foreign jurisdictions. Income tax benefit was $0.5 million for the three months ended June 30, 2022 primarily related to losses in certain foreign jurisdictions.

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Comparison of the Six Months Ended June 30, 2023 and 2022

Net Revenue

Net revenue was $163.5 million for the six months ended June 30, 2023, an increase of $46.1 million, or 39.3%, compared to $117.4 million for the six months ended June 30, 2022. Net revenue is primarily derived from the sale of our products to customers in the United States and certain international markets. The increase in net revenue is primarily due to increased sales of our products as we expanded our customer base in the U.S. and increased sales with our existing customer base. Our expanded product offering of the fourth-generation rechargeable SNM system in January 2023, recharge-free SNM system in March 2022 and the acquisition of the Bulkamid product in February 2021 have also contributed to our expansion of customers and more patients being treated with our existing customers.

Cost of Goods Sold and Gross Margin

We incurred $40.9 million of cost of goods sold for the six months ended June 30, 2023. We incurred $34.0 million of cost of goods sold for the six months ended June 30, 2022. Gross margin was 75.0% in the six months ended June 30, 2023, compared to 71.1% for the six months ended June 30, 2022. The increase in gross margin is primarily due to higher sales volumes and product mix.

Research and Development Expenses

Research and development expenses decreased $1.4 million, or 7.4%, to $17.0 million in the six months ended June 30, 2023, compared to $18.4 million in the six months ended June 30, 2022. The decrease in research and development expenses was primarily attributable to a decrease of $2.6 million in contract R&D and manufacturing costs, a decrease of $1.1 million in royalty expense due to lower net revenue derived from the AMF Licensed Products, partially offset by an increase of $2.4 million related to personnel costs including salaries, wages, sales personnel commissions, stock-based compensation and other employee-related benefits.

General and Administrative Expenses

General and administrative expenses increased $2.3 million, or 11.2%, to $22.9 million in the six months ended June 30, 2023, compared to $20.6 million in the six months ended June 30, 2022, primarily as a result of an increase of $2.9 million in personnel costs including salaries and wages, stock-based compensation and other employee-related benefits, partially offset by a decrease of $0.8 million in legal fees.

Sales and Marketing Expenses

Sales and marketing expenses increased $14.5 million, or 20.0%, to $86.9 million in the six months ended June 30, 2023, compared to $72.4 million in the six months ended June 30, 2022. The increase in sales and marketing expenses was attributed to an increase of $13.9 million related to personnel costs including salaries, wages, sales personnel commissions, stock-based compensation and other employee-related benefits.

Amortization of Intangible Assets

Amortization of intangible assets was $4.5 million in the six months ended June 30, 2023, compared to $4.8 million in the six months ended June 30, 2022. Amortization of intangible assets consisted primarily of technology and customer relationships acquired related to the Contura acquisition.

Acquisition-Related Costs

Acquisition-related costs were $2.4 million and $12.2 million in the six months ended June 30, 2023 and 2022, respectively, which related to the change in fair value of contingent consideration.

Acquired In-Process Research & Development

Acquired in-process research & development was $15.4 million for the six months ended June 30, 2023 which related to the Radian acquisition. We recorded no acquired in-process research & development in the six months ended June 30, 2022.

Other Income (Expense), Net

Other income, net was $8.7 million in the six months ended June 30, 2023 consisting primarily of interest

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income on cash equivalents and short-term investments. Other expense, net was $0.7 million in the six months ended June 30, 2022 consisting primarily of losses on foreign currency transactions, partially offset by interest income on cash equivalents and short-term investments.

Income Tax Benefit

Income tax benefit was $1.1 million for the six months ended June 30, 2023 primarily related to losses in certain foreign jurisdictions. Income tax benefit was $1.6 million for the six months ended June 30, 2022 primarily related to losses in certain foreign jurisdictions.

Liquidity and Capital Resources

We only began full-scale commercialization of our first rechargeable SNM system in late 2019. We have expended significant resources on research and development activities, growing our operations organization and building and training our sales organization.

We incurred net losses of $16.6 million and $44.1 million for the six months ended June 30, 2023 and 2022, respectively, and had an accumulated deficit of $390.9 million as of June 30, 2023 compared to $374.3 million at December 31, 2022. We expect to continue to spend a significant amount of our existing resources on sales and marketing activities as we continue to commercialize and market our products in the United States and internationally.

As of June 30, 2023, we had cash, cash equivalents, and short-term investments of $331.5 million compared to $357.2 million at December 31, 2022. We expect that our cash, cash equivalents, and short-term investments on hand will be sufficient to fund our operations through at least the next 12 months. We fund our operations through a combination of proceeds from public offerings of our common stock and cash receipts from sales of our products. As of June 30, 2023, we had no outstanding borrowings.

Beyond the next 12 months, our cash requirements will depend primarily on the amount of continued cash receipts from sales of our products, as well as our ability to develop or acquire new products, enter new markets, and compete effectively. We cannot accurately predict our long-term cash requirements at this time. We may need to raise additional financing in the future to facilitate our business operations. If we raise additional funds by issuing equity securities, our stockholders could experience dilution. Debt financing, if available, may involve covenants further restricting our operations or our ability to incur additional debt. Any debt financing or additional equity that we raise may contain terms that are not favorable to us or our stockholders. Additional financing may not be available at all, or in amounts or on terms acceptable to us. If we are unable to obtain additional financing when needed to satisfy our liquidity requirements, we may be required to scale back our operations.

Contractual Obligations and Cash Requirements

There have been no material changes to our contractual obligations or material cash requirements from those described in our Annual Report on Form 10-K for the fiscal year ended December 31, 2022.

Cash Flows

The following table presents a summary of our cash flow for the periods indicated (in thousands):

	Six Months Ended June 30,
	2023		2022
Net cash provided by (used in)
Operating activities	$	(19,990)	$	(10,009)
Investing activities	(67,929)		(10,923)
Financing activities	(4,836)		1,924
Effect of exchange rate changes on cash and cash equivalents	(748)		1,366
Net decrease in cash and cash equivalents	$	(93,503)	$	(17,642)

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Net cash used in operating activities

Net cash used in operating activities was $20.0 million for the six months ended June 30, 2023 and consisted primarily of a net loss of $16.6 million and a decrease from changes in net operating assets of $47.6 million, partially offset by non-cash charges of $44.2 million. Net operating assets consisted primarily of inventory and accounts receivable due to the commercial growth in the United States. Non-cash charges consisted primarily of stock-based compensation and acquired in-process research and development.

Net cash used in operating activities was $10.0 million for the six months ended June 30, 2022 and consisted primarily of a net loss of $44.1 million, partially offset by non-cash charges of $31.3 million and an increase from changes in net operating assets of $2.8 million. Net operating assets consisted primarily of inventory and accounts receivable due to the commercial growth of our r-SNM System in the United States and the addition of Bulkamid sales. Non-cash charges consisted primarily of stock-based compensation and change in fair value of contingent consideration.

Net cash used in investing activities

Net cash used in investing activities was $67.9 million for the six months ended June 30, 2023 and consisted of purchases of short-term investments and property and equipment, partially offset by sales and maturities of short-term investments.

Net cash used in investing activities was $10.9 million for the six months ended June 30, 2022 and consisted of purchases of short-term investments and property and equipment.

Net cash (used in) provided by financing activities

Net cash used in financing activities was $4.8 million for the six months ended June 30, 2023 and consisted primarily of payment of contingent consideration recognized at acquisition, partially offset by proceeds from exercise of stock options.

Net cash provided by financing activities was $1.9 million for the six months ended June 30, 2022 and consisted of proceeds from exercise of stock options.

Critical Accounting Policies and Estimates

Our critical accounting policies and estimates are described in “Management’s Discussion and Analysis of Financial Condition and Results of Operations—Critical Accounting Policies and Estimates” in our Annual Report on Form 10-K for the fiscal year ended December 31, 2022, as filed with the SEC on March 1, 2023. We have reviewed and determined that those critical accounting policies and estimates remain our critical accounting policies and estimates as of and for the six months ended June 30, 2023.

Recent Accounting Pronouncements

We have reviewed all recently issued standards and have determined that, other than as disclosed in Note 1 to our unaudited condensed consolidated financial statements included elsewhere in this Quarterly Report on Form 10-Q, such standards will not have a significant impact on our unaudited condensed consolidated financial statements or do not otherwise apply to our operations.

Item 3.    Quantitative and Qualitative Disclosures About Market Risk.

We are exposed to market risks in the ordinary course of our business. These risks primarily include interest rate risk, foreign currency exchange rate risk and inflation risk as follows:

Interest Rate Risk

We had cash, cash equivalents, and short-term investments of $331.5 million as of June 30, 2023, which came from public offerings of our common stock and cash receipts from our product sales. The goals of our investment policy are liquidity and capital preservation and we do not enter into investments for trading or speculative purposes. We believe that we do not have any material exposure to changes in the fair value of these assets as a result of changes in interest rates due to the short term nature of our cash, cash equivalents, and short-term investments. A hypothetical 10% relative change in interest rates during any of the periods presented would not

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have had a material impact on our consolidated financial statements. We do not currently engage in hedging transactions to manage our exposure to interest rate risk.

Foreign Currency Exchange Rate Risk

As we expand internationally our results of operations and cash flows may become increasingly subject to fluctuations due to changes in foreign currency exchange rates. All of our revenue is denominated in U.S. dollars. Our expenses are generally denominated in the currencies in which our operations are located, which is primarily in the United States. The effect of a 10% adverse change in exchange rates on foreign denominated cash, receivables and payables would not have been material for the periods presented. As our operations in countries outside of the United States grow, our results of operations and cash flows may be subject to fluctuations due to changes in foreign currency exchange rates, which could harm our business in the future. To date, we have not entered into any material foreign currency hedging contracts although we may do so in the future.

Inflation Risk

Inflationary factors, such as increases in our cost of goods sold and selling and operating expenses, may adversely affect our operating results. Although we do not believe that inflation has had a material impact on our financial position or results of operations to date, a high rate of inflation in the future may have an adverse effect on our ability to maintain and increase our gross margin and sales and marketing and operating expenses as a percentage of our revenue if the selling prices of our products do not increase as much as or more than these increased costs.

Item 4.    Controls and Procedures.

Limitations on effectiveness of controls and procedures

In designing and evaluating our disclosure controls and procedures, management recognizes that any controls and procedures, no matter how well designed and operated, can provide only reasonable assurance of achieving the desired control objectives. In addition, the design of disclosure controls and procedures must reflect the fact that there are resource constraints and that management is required to apply judgment in evaluating the benefits of possible controls and procedures relative to their costs.

Evaluation of disclosure controls and procedures

Our management, with the participation of our Chief Executive Officer and Chief Financial Officer, evaluated, as of the end of the period covered by this Quarterly Report on Form 10-Q, the effectiveness of our disclosure controls and procedures (as defined in Rules 13a-15(e) and 15d-15(e) under the Securities Exchange Act of 1934, as amended (the Exchange Act). Based on that evaluation, our Chief Executive Officer and Chief Financial Officer concluded that our disclosure controls and procedures were not effective as of June 30, 2023 due to the material weakness in internal control over financial reporting, as described below.

Material Weakness in Internal Control Over Financial Reporting

Management’s assessment of our internal control over financial reporting as of December 31, 2022 identified a material weakness in our internal control over financial reporting. A material weakness is a deficiency, or a combination of deficiencies, in internal control over financial reporting, such that there is a reasonable possibility that a material misstatement of our annual or interim financial statements will not be prevented or detected on a timely basis.

During the year ended December 31, 2021, we determined that a material weakness exists relating to the determination of the fair values of identifiable intangible assets and contingent consideration liability related to business combinations. This control deficiency creates a reasonable possibility that a material misstatement to the consolidated financial statements will not be prevented or detected on a timely basis.

In addition, during the three months ended September 30, 2022 we determined that we have the following additional material weakness in our internal control over financial reporting:

We did not maintain appropriately designed information technology general controls in the areas of user access and segregation of duties related to certain information technology systems that support our financial

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reporting process, including certain controls within inventory and revenue. Additionally, certain manual controls within inventory and revenue that are dependent upon the information derived from the information technology systems are also determined to be ineffective.

Notwithstanding such material weaknesses in internal control over financial reporting, our management, including our Chief Executive Officer and our Chief Financial Officer, has concluded that our consolidated financial statements present fairly, in all material respects, our financial position, results of our operations and our cash flows for the periods presented in this Quarterly Report, in conformity with GAAP.

Remediation Plan

We have identified steps, as further described below, to remediate the material weaknesses described in this Item 4 and to enhance our overall control environment. We are committed to ensuring that our internal control over financial reporting are designed and operating effectively. Our remediation process includes, but is not limited to:

•Conducting a comprehensive review and assessment of internal control over financial reporting to include the design of general information technology controls in the area of user access provisioning and monitoring controls to enforce appropriate system access and segregation of duties for systems supporting our internal controls processes and financial reporting;

•Designing and implementing controls that address the completeness and accuracy of underlying data used in the performance of certain manual controls over accounting transactions and disclosures within revenue and inventory;

•Enhancing the design of controls, including the precision of the management review controls relating to key methodologies, assumptions and inputs used in the determination of the fair value of identifiable intangibles and a contingent consideration liability;

•Implementing a valuation review checklist that includes specific review attributes to ensure sufficient evidence of an effective review is documented and maintained to support management’s conclusions; and

•Expanding personnel with appropriate experience to devote sufficient time and resources to our internal controls over fair value measurements.

During the six months ended June 30, 2023, management implemented our remediation plan regarding the material weakness relating to the determination of the fair values of identifiable intangible assets and contingent consideration liability related to business combinations. During the three months ended June 30, 2023, we completed our testing of the operating effectiveness of the related implemented controls and found them to be effective. As a result, we have concluded the material weakness has been remediated as of June 30, 2023.

We believe that the remediation plan will remediate the material weakness in our internal control over financial reporting surrounding the design of information technology general controls in the areas of user access and segregation of duties related to certain information technology systems that support our financial reporting process. The weakness will not be considered remediated, however, until the applicable controls operate and management has concluded, through testing, that these controls are operating effectively.

As we continue to evaluate and test the remediation plan outlined above, we may also identify additional measures to address the material weakness or modify certain of the remediation procedures described above. We will continue to take steps necessary to remedy the material weakness to reinforce the overall design and capability of our control environment.

Changes in internal control over financial reporting

Except for the changes in connection with our implementation of the remediation plan discussed above, there were no changes in our internal control over financial reporting (as defined in Rules 13a-15(f) and 15d-15(f) under the Exchange Act) during the three months ended June 30, 2023 that have materially affected, or are reasonably likely to materially affect, our internal control over financial reporting.

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PART II—OTHER INFORMATION

Item 1.    Legal Proceedings.

There have been no material developments in the litigation matters disclosed in our Annual Report on Form 10-K for the fiscal year ended December 31, 2022, as filed with the SEC on March 1, 2023, during the quarter ended June 30, 2023.

Item 1A. Risk Factors.

You should carefully consider the information described in the “Risk Factors” section of our Annual Report on Form 10-K for the fiscal year ended December 31, 2022, as filed with the SEC on March 1, 2023. There have been no material changes from the risk factors disclosed in our recent SEC filings, including our most recently filed Form 10-K, as referenced above except as follows:

Any termination or loss of significant rights under the License Agreement would materially and adversely affect our development and commercialization of our rechargeable SNM system.

AMF has alleged that Axonics is in material breach of the License Agreement because it is not paying royalties on its F15 product, and AMF has claimed that it has terminated the License Agreement on that basis. Axonics strongly disagrees that it is required to pay royalties on F15 or that AMF has the right to terminate the License Agreement. Axonics has paid and will continue to pay 4% royalties on the rechargeable products launched to date. If the dispute between the parties cannot be settled amicably, the parties are obligated to go to arbitration. Any effective termination or loss of rights (including exclusivity) under the License Agreement could materially and adversely affect our ability to continue to sell products covered by the License Agreement, which in turn would have a material adverse effect on our business, operating results and prospects.

Item 2.    Unregistered Sales of Equity Securities and Use of Proceeds.

None.

Item 3.    Defaults Upon Senior Securities.

None.

Item 4.    Mine Safety Disclosures.

Not applicable.

Item 5.    Other Information.

None.

37

Item 6.     Exhibits.

EXHIBIT INDEX

Exhibit Number	Exhibit Title
10.1	Lease, dated April 1, 2023, between Sand Canyon Business Center I LLC and Axonics, Inc. (incorporated by reference to the Registrant’s Current Report on Form 8-K filed with the SEC on April 6, 2023)
10.2	Third Amendment to Lease, dated April 1, 2023, between The Irvine Company LLC and Axonics, Inc. (incorporated by reference to the Registrant’s Current Report on Form 8-K filed with the SEC on April 6, 2023)
31.1	Certification of Principal Executive Officer pursuant to Rule 13a-14(a) or Rule 15d-14(a) of the Securities Exchange Act of 1934, as amended.
31.2	Certification of Principal Financial Officer pursuant to Rule 13a-14(a) or Rule 15d-14(a) of the Securities Exchange Act of 1934, as amended.
32.1#	Certifications of Principal Executive Officer pursuant to 18 U.S.C. Section 1350, as adopted pursuant to Section 906 of the Sarbanes-Oxley Act of 2002.
32.2#	Certifications of Principal Financial Officer pursuant to 18 U.S.C. Section 1350, as adopted pursuant to Section 906 of the Sarbanes-Oxley Act of 2002.
101.INS**	Inline XBRL Instance Document.
101.SCH**	Inline XBRL Taxonomy Extension Schema Document.
101.CAL**	Inline XBRL Taxonomy Extension Calculation Linkbase Document.
101.DEF**	Inline XBRL Taxonomy Extension Definition Linkbase Document.
101.LAB**	Inline XBRL Taxonomy Extension Label Linkbase Document.
101.PRE**	Inline XBRL Taxonomy Extension Presentation Linkbase Document.
104	Cover Page Interactive Date File (formatted as Inline XBRL and contained in Exhibit 101).

#

The information in Exhibits 32.1 and 32.2 shall not be deemed “filed” for purposes of Section 18 of the Exchange Act, or otherwise subject to the liabilities of that section, nor shall it be deemed incorporated by reference in any filing under the Securities Act or the Exchange Act (including this Quarterly Report on Form 10-Q), unless the Company specifically incorporates the foregoing information into those documents by reference.

**

In accordance with Rule 402 of Regulation S-T, this interactive data file is deemed not filed or part of this Quarterly Report on Form 10-Q for purposes of Sections 11 or 12 of the Securities Act or Section 18 of the Exchange Act and otherwise is not subject to liability under these sections.

38

SIGNATURES

Pursuant to the requirements of the Securities Exchange Act of 1934, the registrant has duly caused this report to be signed on its behalf by the undersigned thereunto duly authorized.

	AXONICS, INC.
Date: July 31, 2023	By:	/s/ Raymond W. Cohen
		Raymond W. Cohen
		Chief Executive Officer and Director
		(Principal Executive Officer)
Date: July 31, 2023	By:	/s/ Dan L. Dearen
		Dan L. Dearen
		President and Chief Financial Officer
		(Principal Financial and Accounting Officer)

39

EX-31.1

Exhibit 31.1

I, Raymond W. Cohen, certify that:

1.    I have reviewed this Quarterly Report on Form 10-Q of Axonics, Inc.;

2.    Based on my knowledge, this report does not contain any untrue statement of a material fact or omit to state a material fact necessary to make the statements made, in light of the circumstances under which such statements were made, not misleading with respect to the period covered by this report;

3.    Based on my knowledge, the financial statements, and other financial information included in this report, fairly present in all material respects the financial condition, results of operations and cash flows of the registrant as of, and for, the periods presented in this report;

4.    The registrant’s other certifying officer and I are responsible for establishing and maintaining disclosure controls and procedures (as defined in Exchange Act Rules 13a-15(e) and 15d-15(e)) for the registrant and have:

a)    Designed such disclosure controls and procedures, or caused such disclosure controls and procedures to be designed under our supervision, to ensure that material information relating to the registrant, including its consolidated subsidiaries, is made known to us by others within those entities, particularly during the period in which this report is being prepared;

b)    Designed such internal control over financial reporting, or caused such internal control over financial reporting to be designed under our supervision, to provide reasonable assurance regarding the reliability of financial reporting and the preparation of financial statements for external purposes in accordance with generally accepted accounting principles;

c)    Evaluated the effectiveness of the registrant’s disclosure controls and procedures and presented in this report our conclusions about the effectiveness of the disclosure controls and procedures, as of the end of the period covered by this report based on such evaluation; and

d)    Disclosed in this report any change in the registrant’s internal control over financial reporting that occurred during the registrant’s most recent fiscal quarter (the registrant’s fourth fiscal quarter in the case of an annual report) that has materially affected, or is reasonably likely to materially affect, the registrant’s internal control over financial reporting; and

5.    The registrant’s other certifying officer and I have disclosed, based on our most recent evaluation of internal control over financial reporting, to the registrant’s auditors and the audit committee of the registrant’s board of directors (or persons performing the equivalent functions):

a)    All significant deficiencies and material weaknesses in the design or operation of internal control over financial reporting which are reasonably likely to adversely affect the registrant’s ability to record, process, summarize and report financial information; and

b)    Any fraud, whether or not material, that involves management or other employees who have a significant role in the registrant’s internal control over financial reporting.

Date: July 31, 2023	By:	/s/ Raymond W. Cohen
		Raymond W. Cohen
		Chief Executive Officer and Director
		(Principal Executive Officer)

EX-31.2

Exhibit 31.2

I, Dan L. Dearen, certify that:

1.    I have reviewed this Quarterly Report on Form 10-Q of Axonics, Inc.;

2.    Based on my knowledge, this report does not contain any untrue statement of a material fact or omit to state a material fact necessary to make the statements made, in light of the circumstances under which such statements were made, not misleading with respect to the period covered by this report;

3.    Based on my knowledge, the financial statements, and other financial information included in this report, fairly present in all material respects the financial condition, results of operations and cash flows of the registrant as of, and for, the periods presented in this report;

4.    The registrant’s other certifying officer and I are responsible for establishing and maintaining disclosure controls and procedures (as defined in Exchange Act Rules 13a-15(e) and 15d-15(e)) for the registrant and have:

a)    Designed such disclosure controls and procedures, or caused such disclosure controls and procedures to be designed under our supervision, to ensure that material information relating to the registrant, including its consolidated subsidiaries, is made known to us by others within those entities, particularly during the period in which this report is being prepared;

b)    Designed such internal control over financial reporting, or caused such internal control over financial reporting to be designed under our supervision, to provide reasonable assurance regarding the reliability of financial reporting and the preparation of financial statements for external purposes in accordance with generally accepted accounting principles;

c)    Evaluated the effectiveness of the registrant’s disclosure controls and procedures and presented in this report our conclusions about the effectiveness of the disclosure controls and procedures, as of the end of the period covered by this report based on such evaluation; and

d)    Disclosed in this report any change in the registrant’s internal control over financial reporting that occurred during the registrant’s most recent fiscal quarter (the registrant’s fourth fiscal quarter in the case of an annual report) that has materially affected, or is reasonably likely to materially affect, the registrant’s internal control over financial reporting; and

5.    The registrant’s other certifying officer and I have disclosed, based on our most recent evaluation of internal control over financial reporting, to the registrant’s auditors and the audit committee of the registrant’s board of directors (or persons performing the equivalent functions):

a)    All significant deficiencies and material weaknesses in the design or operation of internal control over financial reporting which are reasonably likely to adversely affect the registrant’s ability to record, process, summarize and report financial information; and

b)    Any fraud, whether or not material, that involves management or other employees who have a significant role in the registrant’s internal control over financial reporting.

Date: July 31, 2023	By:	/s/ Dan L. Dearen
		Dan L. Dearen
		President and Chief Financial Officer
		(Principal Financial Officer)

EX-32.1

Exhibit 32.1

CERTIFICATION PURSUANT TO

18 U.S.C. SECTION 1350, AS ADOPTED PURSUANT TO

SECTION 906 OF THE SARBANES-OXLEY ACT OF 2002

In connection with the Quarterly Report of Axonics, Inc. (the “Company”) on Form 10-Q for the quarterly period ended June 30, 2023 as filed with the Securities and Exchange Commission on the date hereof (the “Report”), I certify, pursuant to 18 U.S.C. § 1350, as adopted pursuant to § 906 of the Sarbanes-Oxley Act of 2002, that:

(1)     The Report fully complies with the requirements of Section 13(a) or 15(d) of the Securities Exchange Act of 1934, as amended; and

(2)    The information contained in the Report fairly presents, in all material respects, the financial condition and results of operations of the Company.

Date: July 31, 2023	By:	/s/ Raymond W. Cohen
		Raymond W. Cohen
		Chief Executive Officer and Director
		(Principal Executive Officer)

A signed original of this written statement required by Section 906 has been provided to Axonics, Inc. and will be retained by Axonics, Inc. and furnished to the Securities and Exchange Commission or its staff upon request.

EX-32.2

Exhibit 32.2

CERTIFICATION PURSUANT TO

18 U.S.C. SECTION 1350, AS ADOPTED PURSUANT TO

SECTION 906 OF THE SARBANES-OXLEY ACT OF 2002

In connection with the Quarterly Report of Axonics, Inc. (the “Company”) on Form 10-Q for the quarterly period ended June 30, 2023 as filed with the Securities and Exchange Commission on the date hereof (the “Report”), I certify, pursuant to 18 U.S.C. § 1350, as adopted pursuant to § 906 of the Sarbanes-Oxley Act of 2002, that:

(1)     The Report fully complies with the requirements of Section 13(a) or 15(d) of the Securities Exchange Act of 1934, as amended; and

(2)    The information contained in the Report fairly presents, in all material respects, the financial condition and results of operations of the Company.

Date: July 31, 2023	By:	/s/ Dan L. Dearen
		Dan L. Dearen
		President and Chief Financial Officer
		(Principal Financial Officer)

A signed original of this written statement required by Section 906 has been provided to Axonics, Inc. and will be retained by Axonics, Inc. and furnished to the Securities and Exchange Commission or its staff upon request.

XML

Cover - shares	6 Months Ended
	Jun. 30, 2023	Jul. 28, 2023
Cover [Abstract]
Document Type	10-Q
Document Quarterly Report	true
Document Period End Date	Jun. 30, 2023
Document Transition Report	false
Entity File Number	001-38721
Entity Registrant Name	Axonics, Inc.
Entity Incorporation, State or Country Code	DE
Entity Tax Identification Number	45-4744083
Entity Address, Address Line One	26 Technology Drive
Entity Address, City or Town	Irvine,
Entity Address, State or Province	CA
Entity Address, Postal Zip Code	92618
City Area Code	(949)
Local Phone Number	396-6322
Title of 12(b) Security	Common stock, par value $0.0001 per share
Trading Symbol	AXNX
Security Exchange Name	NASDAQ
Entity Current Reporting Status	Yes
Entity Interactive Data Current	Yes
Entity Filer Category	Large Accelerated Filer
Entity Small Business	false
Entity Emerging Growth Company	false
Entity Shell Company	false
Entity Common Stock, Shares Outstanding		50,460,801
Amendment Flag	false
Document Fiscal Year Focus	2023
Document Fiscal Period Focus	Q2
Entity Central Index Key	0001603756
Current Fiscal Year End Date	--12-31

XML

Condensed Consolidated Balance Sheets - USD ($) $ in Thousands	Jun. 30, 2023	Dec. 31, 2022
Current assets
Cash and cash equivalents	$ 145,343	$ 238,846
Short-term investments	186,173	118,365
Accounts receivable, net of allowance for credit losses of $367 and $321 at June 30, 2023 and December 31, 2022, respectively	47,436	44,817
Inventory, net	70,083	55,765
Prepaid expenses and other current assets	6,361	7,282
Total current assets	455,396	465,075
Property and equipment, net	6,349	6,798
Intangible assets, net	85,543	86,253
Other assets	2,817	6,813
Goodwill	98,880	94,414
Total assets	648,985	659,353
Current liabilities
Accounts payable	12,185	9,070
Accrued liabilities	5,571	6,520
Accrued compensation and benefits	12,559	15,495
Operating lease liability, current portion	1,769	1,562
Other current liabilities	0	32,600
Total current liabilities	32,084	65,247
Operating lease liability, net of current portion	1,199	7,555
Deferred tax liabilities, net	15,173	16,412
Total liabilities	48,456	89,214
Commitments and contingencies (Note 3)
Stockholders’ equity
Preferred stock, par value $0.0001 per share; 10,000,000 shares authorized, no shares issued and outstanding at June 30, 2023 and December 31, 2022	0	0
Common stock, par value $0.0001, 75,000,000 shares authorized at June 30, 2023 and December 31, 2022; 50,461,257 and 49,546,727 shares issued and outstanding at June 30, 2023 and December 31, 2022, respectively	5	5
Additional paid-in capital	1,009,704	969,545
Accumulated deficit	(390,854)	(374,264)
Accumulated other comprehensive loss	(18,326)	(25,147)
Total stockholders’ equity	600,529	570,139
Total liabilities and stockholders’ equity	$ 648,985	$ 659,353

XML

Condensed Consolidated Balance Sheets (Parenthetical) - USD ($) $ in Thousands	Jun. 30, 2023	Dec. 31, 2022
Statement of Financial Position [Abstract]
Allowance for credit losses	$ 367	$ 321
Preferred stock, par value (in USD per share)	$ 0.0001	$ 0.0001
Preferred stock authorized (in shares)	10,000,000	10,000,000
Preferred stock issued (in shares)	0	0
Preferred stock outstanding (in shares)	0	0
Common stock, par value (in USD per share)	$ 0.0001	$ 0.0001
Common stock authorized (in shares)	75,000,000	75,000,000
Common stock issued (in shares)	50,461,257	49,546,727
Common stock outstanding (in shares)	50,461,257	49,546,727

XML

Condensed Consolidated Statements of Comprehensive Loss - USD ($) $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2023	Jun. 30, 2022	Jun. 30, 2023	Jun. 30, 2022
Statement of Comprehensive Income [Abstract]
Net revenue	$ 92,894	$ 68,980	$ 163,544	$ 117,400
Cost of goods sold	22,704	18,784	40,854	33,962
Gross profit	70,190	50,196	122,690	83,438
Operating expenses
Research and development	8,949	7,135	17,005	18,371
General and administrative	10,713	10,572	22,881	20,585
Sales and marketing	44,270	39,381	86,924	72,444
Amortization of intangible assets	2,279	2,332	4,501	4,795
Acquisition-related costs	602	12,205	2,368	12,205
Acquired in-process research & development	15,447	0	15,447	0
Total operating expenses	82,260	71,625	149,126	128,400
Loss from operations	(12,070)	(21,429)	(26,436)	(44,962)
Other income (expense)
Interest and other income	4,250	360	7,878	403
Interest and other expense	174	(839)	857	(1,128)
Other income (expense), net	4,424	(479)	8,735	(725)
Loss before income tax benefit	(7,646)	(21,908)	(17,701)	(45,687)
Income tax benefit	(304)	(465)	(1,111)	(1,576)
Net loss	(7,342)	(21,443)	(16,590)	(44,111)
Foreign currency translation adjustment	3,750	(12,648)	6,821	(17,568)
Comprehensive loss	$ (3,592)	$ (34,091)	$ (9,769)	$ (61,679)
Net loss per share, basic (in USD per share)	$ (0.15)	$ (0.47)	$ (0.34)	$ (0.98)
Net loss per share, diluted (in USD per share)	$ (0.15)	$ (0.47)	$ (0.34)	$ (0.98)
Weighted-average shares used to compute basic net loss per share (in shares)	49,088,373	45,311,001	48,835,135	45,225,494
Weighted-average shares used to compute diluted net loss per share (in shares)	49,088,373	45,311,001	48,835,135	45,225,494

XML

Condensed Consolidated Statements of Stockholders' Equity - USD ($) $ in Thousands	Total	Common Stock	Additional Paid-in Capital	Accumulated Deficit	Accumulated Other Comprehensive Loss
Balance at beginning of period (in shares) at Dec. 31, 2021		46,330,167
Balance at beginning of period at Dec. 31, 2021	$ 482,438	$ 5	$ 803,559	$ (314,566)	$ (6,560)
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Issuance of common stock for employee stock option exercises for cash (in shares)		91,286
Issuance of common stock for employee stock option exercises for cash	1,444		1,444
Restricted Shares Award (RSA) issuances and forfeitures for terminations, net and stock-based compensation (in shares)		312,479
Restricted Shares Award (RSA) issuances and forfeitures for terminations, net and stock-based compensation	5,633		5,633
Issuance of common stock for vesting of Restricted Stock Units (RSU) and stock-based compensation (in shares)		268,930
Issuance of common stock for vesting of Restricted Stock Units (RSU) and stock-based compensation	1,505		1,505
Foreign currency translation adjustment	(4,920)				(4,920)
Net loss	(22,668)			(22,668)
Balance at end of period (in shares) at Mar. 31, 2022		47,002,862
Balance at end of period at Mar. 31, 2022	463,432	$ 5	812,141	(337,234)	(11,480)
Balance at beginning of period (in shares) at Dec. 31, 2021		46,330,167
Balance at beginning of period at Dec. 31, 2021	482,438	$ 5	803,559	(314,566)	(6,560)
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Issuance of common stock for acquisition of in-process research & development	0
Foreign currency translation adjustment	(17,568)
Net loss	(44,111)
Balance at end of period (in shares) at Jun. 30, 2022		47,117,716
Balance at end of period at Jun. 30, 2022	437,726	$ 5	820,526	(358,677)	(24,128)
Balance at beginning of period (in shares) at Mar. 31, 2022		47,002,862
Balance at beginning of period at Mar. 31, 2022	463,432	$ 5	812,141	(337,234)	(11,480)
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Issuance of common stock for employee stock option exercises for cash (in shares)		35,803
Issuance of common stock for employee stock option exercises for cash	480		480
Restricted Shares Award (RSA) issuances and forfeitures for terminations, net and stock-based compensation (in shares)		79,051
Restricted Shares Award (RSA) issuances and forfeitures for terminations, net and stock-based compensation	6,490		6,490
Issuance of common stock for vesting of Restricted Stock Units (RSU) and stock-based compensation	1,415		1,415
Foreign currency translation adjustment	(12,648)				(12,648)
Net loss	(21,443)			(21,443)
Balance at end of period (in shares) at Jun. 30, 2022		47,117,716
Balance at end of period at Jun. 30, 2022	$ 437,726	$ 5	820,526	(358,677)	(24,128)
Balance at beginning of period (in shares) at Dec. 31, 2022	49,546,727	49,546,727
Balance at beginning of period at Dec. 31, 2022	$ 570,139	$ 5	969,545	(374,264)	(25,147)
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Issuance of common stock for employee stock option exercises for cash (in shares)		116,452
Issuance of common stock for employee stock option exercises for cash	1,930		1,930
Restricted Shares Award (RSA) issuances and forfeitures for terminations, net and stock-based compensation (in shares)		247,770
Restricted Shares Award (RSA) issuances and forfeitures for terminations, net and stock-based compensation	7,295		7,295
Issuance of common stock for vesting of Restricted Stock Units (RSU) and stock-based compensation (in shares)		199,718
Issuance of common stock for vesting of Restricted Stock Units (RSU) and stock-based compensation	3,419		3,419
Foreign currency translation adjustment	3,071				3,071
Net loss	(9,248)			(9,248)
Balance at end of period (in shares) at Mar. 31, 2023		50,110,667
Balance at end of period at Mar. 31, 2023	$ 576,606	$ 5	982,189	(383,512)	(22,076)
Balance at beginning of period (in shares) at Dec. 31, 2022	49,546,727	49,546,727
Balance at beginning of period at Dec. 31, 2022	$ 570,139	$ 5	969,545	(374,264)	(25,147)
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Issuance of common stock for acquisition of in-process research & development	15,447
Foreign currency translation adjustment	6,821
Net loss	$ (16,590)
Balance at end of period (in shares) at Jun. 30, 2023	50,461,257	50,461,257
Balance at end of period at Jun. 30, 2023	$ 600,529	$ 5	1,009,704	(390,854)	(18,326)
Balance at beginning of period (in shares) at Mar. 31, 2023		50,110,667
Balance at beginning of period at Mar. 31, 2023	576,606	$ 5	982,189	(383,512)	(22,076)
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Issuance of common stock for employee stock option exercises for cash (in shares)		43,229
Issuance of common stock for employee stock option exercises for cash	864		864
Restricted Shares Award (RSA) issuances and forfeitures for terminations, net and stock-based compensation (in shares)		42,578
Restricted Shares Award (RSA) issuances and forfeitures for terminations, net and stock-based compensation	7,676		7,676
Issuance of common stock for vesting of Restricted Stock Units (RSU) and stock-based compensation	3,528		3,528
Issuance of common stock for acquisition of in-process research & development (in shares)		264,783
Issuance of common stock for acquisition of in-process research & development	15,447		15,447
Foreign currency translation adjustment	3,750				3,750
Net loss	$ (7,342)			(7,342)
Balance at end of period (in shares) at Jun. 30, 2023	50,461,257	50,461,257
Balance at end of period at Jun. 30, 2023	$ 600,529	$ 5	$ 1,009,704	$ (390,854)	$ (18,326)

XML

Condensed Consolidated Statements of Cash Flows - USD ($) $ in Thousands	6 Months Ended
	Jun. 30, 2023	Jun. 30, 2022
Cash Flows from Operating Activities
Net loss	$ (16,590)	$ (44,111)
Adjustments to reconcile net loss to net cash used in operating activities
Depreciation and amortization	6,041	5,920
Stock-based compensation	21,918	15,043
Acquired in-process research & development	15,447	0
Provision for (reversal of) allowance of credit losses	46	(50)
Change in fair value of contingent consideration	2,400	12,030
Deferred income taxes and other items, net	(1,700)	(1,638)
Changes in operating assets and liabilities
Accounts receivable	(2,556)	(7,260)
Inventory	(14,480)	6,220
Prepaid expenses and other current assets	(9)	1,514
Other assets	(1,868)	17
Accounts payable	2,968	2,153
Accrued liabilities	(968)	1,582
Accrued compensation and benefits	(2,945)	(1,465)
Lease liability	(324)	36
Other liabilities	(27,370)	0
Net cash used in operating activities	(19,990)	(10,009)
Cash Flows from Investing Activities
Purchases of property and equipment	(1,050)	(925)
Purchases of short-term investments	(174,616)	(9,998)
Proceeds from sales and maturities of short-term investments	107,737	0
Net cash used in investing activities	(67,929)	(10,923)
Cash Flows from Financing Activities
Payment of contingent consideration recognized at acquisition	(7,630)	0
Proceeds from exercise of stock options	2,794	1,924
Net cash (used in) provided by financing activities	(4,836)	1,924
Effect of exchange rate changes on cash and cash equivalents	(748)	1,366
Net decrease in cash and cash equivalents	(93,503)	(17,642)
Cash and cash equivalents, beginning of year	238,846	220,878
Cash and cash equivalents, end of period	145,343	203,236
Supplemental Disclosure of Cash Flow Information
Cash paid for interest	39	1
Cash paid for taxes	94	639
Noncash Investing and Financing Activities
Property and equipment acquired but not yet paid	41	513
Common stock issuance for acquired in-process research and development	$ 15,447	$ 0

XML

Nature of Operations and Summary of Significant Accounting Policies

6 Months Ended

Jun. 30, 2023

Organization, Consolidation and Presentation of Financial Statements [Abstract]

Nature of Operations and Summary of Significant Accounting Policies

Nature of Operations and Summary of Significant Accounting Policies

Nature of Operations

Axonics, Inc. (the Company) was incorporated in the state of Delaware on March 2, 2012 under the name American Restorative Medicine, Inc. The Company had no operations until October 1, 2013, when the license agreement between Alfred E. Mann Foundation for Scientific Research (AMF) and the Company (the License Agreement) was entered into. In August 2013, the Company changed its name to Axonics Modulation Technologies, Inc. In March 2021, the Company changed its name to Axonics, Inc.

The Company is a medical technology company that develops and commercializes innovative and minimally invasive products to treat bladder and bowel dysfunction. The Company has designed and developed both rechargeable (R20™) and recharge-free (F15™) implantable sacral neuromodulation (SNM) systems, which deliver mild electrical pulses to the targeted sacral nerve in order to restore normal communication to and from the brain to reduce the symptoms of overactive bladder (OAB), urinary retention (UR) and fecal incontinence (FI). The Company’s products are protected by intellectual property based on Company-generated innovations and patents and other intellectual property licensed from AMF. The Company has marketing approvals in the United States, Europe, Canada, and Australia for all relevant clinical indications. The premarket approval (PMA) application for the Company’s first rechargeable SNM system for the treatment of FI was approved by the U.S. Food and Drug Administration (FDA) on September 6, 2019, and the PMA application for the first rechargeable SNM system for the treatment of OAB and UR was approved by the FDA on November 13, 2019. Accordingly, the Company began U.S. commercialization of its first rechargeable SNM system in the fourth quarter of 2019.

Beginning in February 2021 with the acquisition of Contura Limited, the Company also markets Bulkamid®, a urethral bulking agent to treat female stress urinary incontinence (SUI). Beginning in March 2022 with the FDA approval of the Company’s long-lived, recharge-free F15 SNM implantable stimulator, the Company now markets and sells the F15 recharge-free system to customers in the United States in addition to the rechargeable SNM system. The new recharge-free SNM system and Bulkamid are protected by intellectual property based on Company-generated innovations or patents acquired as part of the Contura acquisition.

August 2022 Follow-On Offering

On August 5, 2022, the Company completed a follow-on offering by issuing 2,012,500 shares of common stock, at an offering price of $63.85 per share, inclusive of 262,500 shares of the Company’s common stock issued upon the exercise by the underwriters of their option to purchase additional shares. The net proceeds to the Company were approximately $128.3 million, after deducting offering expenses payable by the Company.

Acquisition of in-process research & development from Radian, LLC

In April 2023, the Company acquired the assets of Radian, LLC (the Seller), for total consideration of the issuance of 264,783 shares of common stock and a potential future milestone payment of up to $2.5 million (the Radian acquisition).

The Company evaluated this acquisition in accordance with Accounting Standards Codification (ASC) 805, Business Combinations, to determine whether the asset acquired met the definition of a business. Included in the IPR&D is the historical know-how, software, formula protocols, designs, and procedures expected to be needed to complete the technology asset and receive regulatory approval. The Company concluded that the IPR&D is an identifiable intangible asset that would be accounted for as a single asset in a business combination. The Company also qualitatively concluded that there is no fair value associated with any other assets included in the acquisition. Therefore, all of the consideration in the transaction was allocated to the IPR&D. As such, the Company concluded that substantially all of the fair value of the gross assets acquired was concentrated in the single IPR&D asset and the set was not a business.

The Company is planning to use the acquired IPR&D technology to provide a solution to make peripheral nerve evaluation lead placement easier, faster, and more accurate. Although the acquired technology may have utility in other medical procedures, future development decisions for the acquired technology will be contingent upon the receipt of required regulatory approvals. As such, the acquired technology does not have an alternative

future use at the acquisition date. In accordance with ASC 730, Research and Development, the Company concluded the entire purchase price for the asset acquisition was an expense on the acquisition date.

The consideration transferred at closing had an acquisition date fair value of $15.4 million based on a per share value of $58.34 on the acquisition date and was recognized immediately as IPR&D expense in the unaudited condensed consolidated statements of comprehensive loss for the three and six months ended June 30, 2023. The potential future milestone payment of $2.5 million, payable in either cash or shares of common stock, will become payable upon the Company receiving from the FDA 510(k) clearance for the acquired IPR&D technology.

Principles of Consolidation

The accompanying unaudited interim condensed consolidated financial statements include the accounts of the Company and its wholly-owned subsidiaries: Axonics Europe, S.A.S., Axonics Modulation Technologies U.K. Limited, Axonics Modulation Technologies Australia Pty Ltd, Axonics Women’s Health Limited, Bulkamid SARL, Axonics GmbH, and Contura, Inc. Intercompany accounts and transactions have been eliminated in consolidation.

Basis of Presentation and Liquidity

Interim Financial Statements

The unaudited interim condensed consolidated financial statements and related footnote disclosures as of and for the three and six months ended June 30, 2023 are unaudited, and are not necessarily indicative of the Company’s operating results for a full year. The unaudited interim condensed consolidated financial statements include all normal and recurring adjustments necessary for a fair presentation of the Company’s financial results for the three and six months ended June 30, 2023 in accordance with United States generally accepted accounting principles (GAAP), however, certain information and footnote disclosures normally included in annual financial statements prepared in accordance with GAAP have been condensed or omitted pursuant to the U.S. Securities and Exchange Commission (SEC) rules and regulations relating to interim financial statements. The accompanying unaudited condensed consolidated financial statements should be read in conjunction with the Company’s audited consolidated financial statements and notes thereto included within the Company’s Annual Report on Form 10-K for the fiscal year ended December 31, 2022 (filed with the SEC on March 1, 2023).

Liquidity

The Company began full-scale commercialization of its first r-SNM System in late 2019. The Company has expended significant resources on research and development activities, growing its operations organization and building and training its sales organization.

The Company incurred net losses of $16.6 million and $44.1 million for the six months ended June 30, 2023 and 2022, respectively, and had an accumulated deficit of $390.9 million as of June 30, 2023 compared to $374.3 million at December 31, 2022. The Company expects to continue to spend a significant amount of its existing resources on sales and marketing activities as the Company continues to invest in commercializing and marketing its products in the United States and internationally.

As of June 30, 2023, the Company had cash, cash equivalents, and short-term investments of $331.5 million compared to $357.2 million at December 31, 2022. The Company expects that its cash, cash equivalents, and short-term investments on hand will be sufficient to fund its operations through at least the next 12 months. The Company funds its operations through a combination of proceeds from public offerings of its common stock and cash receipts from sales of its products. As of June 30, 2023, the Company had no outstanding borrowings.

The Company may need to raise additional financing in the future to facilitate its business operations. If the Company raises additional funds by issuing equity securities, its stockholders could experience dilution. Debt financing, if available, may involve covenants further restricting its operations or its ability to incur additional debt. Any debt financing or additional equity that the Company raises may contain terms that are not favorable to the Company or its stockholders. Additional financing may not be available at all, or in amounts or on terms acceptable to the Company. If the Company is unable to obtain additional financing when needed to satisfy its liquidity requirements, the Company may be required to scale back its operations.

Use of Estimates

The preparation of unaudited condensed consolidated financial statements in conformity with GAAP requires the Company’s management to make estimates and judgments that affect the reported amounts of assets, liabilities, and expenses, and related disclosures of contingent assets and liabilities. The Company bases its estimates on historical experience and on various other assumptions that it believes to be reasonable under the circumstances. The results of this evaluation then form the basis for making judgments about the carrying values of assets and liabilities that are not readily apparent from other sources. Actual results may differ from these estimates, and such differences may be material to the consolidated financial statements. Significant items subject to such estimates and assumptions include the useful lives of property and equipment and intangible assets, the valuation of deferred income tax assets and liabilities, the valuation of contingent consideration liability, the valuation of stock-based compensation, the product returns reserve, the inventory obsolescence reserve and accounts receivable allowance for credit losses.

Revenue Recognition

Revenue recognized during the six months ended June 30, 2023 and 2022 relates entirely to the sale of the Company’s products to its customers and distributors.

The Company has revenue arrangements that consist of a single performance obligation. The Company recognizes revenue at the point in time when it transfers control of promised goods to its customers. Revenue is measured as the amount of consideration expected to be received in exchange for transferring goods. The amount of revenue that is recognized is based on the transaction price, which represents the invoiced amount and includes estimates of variable consideration such as discounts, where applicable. The Company also sells to distributors and applies the same policies as its revenue arrangements with customers, specifically that revenue is recognized at the point in time when it transfers control of promised goods to its distributors. The Company does not offer rights of return or price protection. The amount of variable consideration included in the transaction price may be constrained and is included only to the extent that it is probable that a significant reversal in the amount of the cumulative revenue recognized under the contract will not occur in a future period. Payment terms, typically less than three months, do not include a significant financing component. The Company extends credit to its customers and distributors based upon an evaluation of their financial condition and credit history and generally requires no collateral. The Company does not have any contract balances related to product sales. The Company also does not have significant contract acquisition costs related to product sales.

In accordance with Company policy and based on the Company’s historical experience, the allowance for product returns was $0.2 million and $0.2 million at June 30, 2023 and December 31, 2022, respectively, and is recorded as a reduction of gross revenue in its unaudited condensed consolidated statements of comprehensive loss. Damaged or defective products are replaced at no charge under the Company’s standard warranty. For the three and six months ended June 30, 2023, the replacement costs were minimal and $0.1 million, respectively. For the three and six months ended June 30, 2022, the replacement costs were minimal and $0.1 million, respectively. The replacement costs are recorded within the sales and marketing expenses in its unaudited condensed consolidated statements of comprehensive loss.

The Company offers its standard warranty to all customers. The Company does not sell any warranties on a standalone basis. The Company’s warranty provides that its products are free of material defects and conform to specifications, and includes an offer to repair, replace or refund the purchase price of defective products. This assurance does not constitute a service and is not considered a separate performance obligation. The Company estimates warranty liabilities at the time of revenue recognition and records it as a charge to sales and marketing expense. The warranty liability as of June 30, 2023 and December 31, 2022 was $0.1 million and $0.1 million, respectively.

Shipping and handling costs incurred for the delivery of goods to customers and distributors are included in cost of goods sold. Amounts billed to customers and distributors for shipping and handling are included in net revenue.

The following table provides additional information pertaining to net revenue disaggregated by product and geographic market for the three and six months ended June 30, 2023 and 2022 (in thousands):

	Three Months Ended June 30,				Six Months Ended June 30,
	2023		2022		2023		2022
SNM net revenue
United States	$	72,205	$	54,468	$	126,058	$	92,183
International markets	1,983		1,290		3,288		2,645
	$	74,188	$	55,758	$	129,346	$	94,828
Bulkamid net revenue
United States	$	14,806	$	10,223	$	26,419	$	16,792
International markets	3,900		2,999		7,779		5,780
	$	18,706	$	13,222	$	34,198	$	22,572
Total net revenue	$	92,894	$	68,980	$	163,544	$	117,400

Allowance for Credit Losses

The Company makes estimates of the collectability of accounts receivable in accordance with Accounting Standards Update (ASU) 2016-13, “Financial Instruments—Credit Losses (Topic 326): Measurement of Credit Losses on Financial Instruments.” The Company’s estimate of future credit losses is made by management based upon historical bad debts, customer receivable balances, age of customer receivable balances, customers’ financial conditions and reasonable forecasted economic trends. Despite the Company’s efforts to minimize credit risk exposure, customers could be adversely affected if future economic and industry trends change in such a manner as to negatively impact their cash flows. As a result, the Company’s future collection experience can differ significantly from historical collection trends. If the Company’s customers experience a negative impact on their cash flows, it could have a material adverse effect on the Company’s results of operations and financial condition.

The following table summarizes the changes in our allowance for credit losses (in thousands):

	Six Months Ended June 30,
	2023		2022
Balance at beginning of period	$	321	$	355
Write-offs	—		—
Bad debt expense (recoveries)	46		(50)
Balance at end of period	$	367	$	305

Cash and Cash Equivalents

Cash equivalents consist of short-term, highly liquid investments purchased with a maturity of three months or less. Financial instruments that potentially subject the Company to a concentration of credit risk consist of cash and cash equivalents. At times, the cash and cash equivalent balances may exceed federally insured limits. The Company does not believe that this results in any significant credit risk as the Company’s policy is to place its cash and cash equivalents in highly-rated financial institutions. The Company also holds cash in foreign banks that are not federally insured. The Company has not experienced any losses on its deposits of cash and cash equivalents.

Fair Value of Financial Instruments

Fair value is defined as the price that would be received to sell an asset or paid to transfer a liability in an orderly transaction between market participants at the measurement date. A three-level fair value hierarchy prioritizes the inputs used to measure fair value. The hierarchy requires entities to maximize the use of observable inputs and minimize the use of unobservable inputs. The three levels of inputs used to measure fair value are as follows:

•Level 1: Inputs are unadjusted quoted prices in active markets for identical assets or liabilities.

•Level 2: Inputs are quoted prices for similar assets and liabilities in active markets or quoted prices for identical or similar instruments in markets that are not active and model-derived valuations in which all significant inputs and significant value drivers are observable in active markets.

•Level 3: Inputs are unobservable inputs based on the Company’s assumptions and valuation techniques used to measure assets and liabilities at fair value. The inputs require significant management judgment or estimation.

Level 1 investments include U.S. government and agency securities, which are valued based on prices readily available in the active markets in which those securities are traded. Level 2 investments include commercial paper and corporate notes, which is valued on a recurring basis based on inputs that are readily available in public markets or can be derived from information available in publicly quoted markets.

The Company’s assessment of the significance of an input to the fair value measurement requires judgment, which may affect the valuation of fair value assets and liabilities and their placement within the fair value hierarchy levels. The carrying amounts reported in the unaudited condensed consolidated financial statements approximate the fair value for cash and cash equivalents, accounts receivable, and accounts payables, due to their short-term nature.

The purchase price of business acquisitions is primarily allocated to the tangible and identifiable intangible assets acquired and liabilities assumed based on their estimated fair values on the acquisition date, with the excess recorded as goodwill.

Certain of the Company’s business combinations involve potential payment of future consideration that is contingent upon the achievement of certain product development milestones and/or contingent on the acquired business reaching certain performance milestones. A liability is recorded for the estimated fair value of the contingent consideration on the acquisition date. The fair value of the contingent consideration is remeasured at each reporting period, and the change in fair value is recognized within operating expenses in the consolidated statements of comprehensive loss.

On February 25, 2021, the Company acquired Contura Limited and its Bulkamid product, a urethral bulking agent indicated for the treatment of female SUI. In consideration for the acquisition, the Company paid approximately $141.3 million in cash and issued 1,096,583 shares of our common stock. The agreement also provided that the Company may pay an additional $35 million in the event Bulkamid sales in any consecutive 12-month period exceed $50 million (the Milestone) before December 31, 2024, with payment due within 50 business days following the quarter in which the Milestone has been met.

Contingent consideration represents contingent milestone, performance and revenue-sharing payment obligations related to acquisitions and is measured at fair value, based on significant inputs not observable in the market, which represents a Level 3 measurement within the fair value hierarchy. The valuation of contingent consideration is estimated using a binary option-based approach with assumptions the Company believes would be made by a market participant. Significant inputs include projected revenues, discount rates, volatility factors and risk-free rates. The Company assesses these assumptions on an ongoing basis as additional data impacting the assumptions is obtained and any change in fair value of the contingent consideration is recorded within acquisition-related costs in the consolidated statements of comprehensive loss. Significant increases or decreases in any of those inputs in isolation would result in a significantly lower or higher fair value measurement. Generally, a change in the assumption used for the projected revenues would result in a directionally similar change to the overall estimate of the contingent consideration. At March 31, 2023, the Milestone has been met and payment was made during the three months ended June 30, 2023. The fair value of contingent consideration of $32.6 million at December 31,

2022, is reflected in other current liabilities in the Company’s unaudited condensed consolidated balance sheets.

The following table summarizes the changes in the fair value of recurring Level 3 fair value measurements during the six months ended June 30, 2023 and 2022 (in thousands):

	Six Months Ended June 30,
	2023		2022
Liabilities
Contingent consideration:
Balance at beginning of period	$	32,600	$	10,370
Change in fair value included in earnings	2,400		12,030
Payment made	(35,000)		—
Balance at end of period	$	—	$	22,400

There were no transfers between Levels 1, 2 or 3 for the periods presented.

Investment Securities

The Company classifies its investment securities as available-for-sale. Those investments in debt securities with maturities less than 12 months at the balance sheet date are considered short-term investments. Those investments in debt securities with maturities greater than 12 months at the balance sheet date are considered long-term investments. The Company’s investment securities classified as available-for-sale are recorded at fair value based on the fair value hierarchy (Level 1 and Level 2 inputs in the fair value hierarchy), and consists primarily of commercial paper, corporate notes and U.S. government and agency securities. Unrealized gains or losses, deemed temporary in nature, are reported as other comprehensive income (loss) within the unaudited condensed consolidated statements of comprehensive loss. There were no unrealized gains or losses during the three and six months ended June 30, 2023 and 2022.

A decline in the fair value of any security below cost that is deemed other than temporary results in a charge to net income (loss) and the corresponding establishment of a credit loss allowance for the security. Premiums (discounts) are amortized (accreted) over the life of the related security as an adjustment to yield using the straight-line interest method. Dividend, accretion and interest income are recognized when earned. Realized gains or losses are included in net loss and are derived using the specific identification method for determining the cost of securities sold.

The following table presents the fair value hierarchy for those assets measured at fair value on a recurring basis as of June 30, 2023 and December 31, 2022 (in thousands):

	Fair Value Measurements at June 30, 2023
Assets:	Level 1		Level 2		Level 3		Total
Commercial paper	$	—	$	119,763	$	—	$	119,763
Corporate notes	—		5,700		—		5,700
U.S. government and agency securities	171,760		—		—		171,760
	$	171,760	$	125,463	$	—	$	297,223

_____________________________________________

(1)    As of June 30, 2023, commercial paper investments of $81.1 million and U.S. government and agency securities of $30.0 million are included in cash and cash equivalents on the unaudited condensed consolidated balance sheets, as the investments had a maturity of three months or less from the date of purchase.

	Fair Value Measurements at December 31, 2022
Assets:	Level 1		Level 2		Level 3		Total
Commercial paper	$	—	$	175,548	$	—	$	175,548
Corporate notes	—		4,675		—		4,675
U.S. government and agency securities	75,212		—		—		75,212
	$	75,212	$	180,223	$	—	$	255,435

_____________________________________________

(1)    As of December 31, 2022, commercial paper investments of $131.1 million, U.S. government and agency securities of $4.0 million, and corporate notes of $2.0 million are included in cash and cash equivalents on the unaudited condensed consolidated balance sheets, as the investments had a maturity of three months or less from the date of purchase.

The Company holds investments in marketable debt securities that are classified and accounted for as cash equivalents or available-for-sale and are remeasured on a recurring basis. All of the Company’s available-for-sale debt securities are classified on the unaudited condensed consolidated balance sheets as cash equivalents or short-term investments. The following table summarizes the Company’s cash equivalents and investments in available-for-sale debt securities by significant investment category as of June 30, 2023 and December 31, 2022 (in thousands):

	June 30, 2023
	Cost		Unrealized gains		Unrealized losses		Fair value
Cash equivalents:
Commercial paper	$	81,063	$	—	$	—	$	81,063
Corporate notes	—		—		—		—
U.S. government and agency securities	29,987		—		—		29,987
Total cash equivalents	$	111,050	$	—	$	—	$	111,050
Short-term investments:
Commercial paper	$	38,700	$	—	$	—	$	38,700
Corporate notes	5,709		—		(9)		5,700
U.S. government and agency securities	141,805		3		(35)		141,773
Total short-term investments	$	186,214	$	3	$	(44)	$	186,173
Total	$	297,264	$	3	$	(44)	$	297,223

	December 31, 2022
	Cost		Unrealized gains		Unrealized losses		Fair value
Cash equivalents:
Commercial paper	$	131,075	$	—	$	—	$	131,075
Corporate notes	2,013		—		—		2,013
U.S. government and agency securities	3,982		—		—		3,982
Total cash equivalents	$	137,070	$	—	$	—	$	137,070
Short-term investments:
Commercial paper	$	44,473	$	—	$	—	$	44,473
Corporate notes	2,664		—		(2)		2,662
U.S. government and agency securities	71,342		6		(118)		71,230
Total short-term investments	$	118,479	$	6	$	(120)	$	118,365
Total	$	255,549	$	6	$	(120)	$	255,435

Foreign Currency Translation

The functional currencies of the Company’s subsidiaries are currencies other than the U.S. dollar. The Company translates assets and liabilities of the foreign subsidiaries into U.S. dollars at the exchange rate in effect on the balance sheet date. Revenue and expenses of the subsidiaries are translated into U.S. dollars at the average exchange rate during the period. Gains or losses from these translation adjustments are reported as a separate component of stockholders’ equity in accumulated other comprehensive gain or loss until there is a sale or complete or substantially complete liquidation of the Company’s investment in the foreign subsidiary at which time the gains or losses will be realized and included in net income (loss). As of June 30, 2023 and December 31, 2022, all foreign currency translation gains (losses) have been unrealized and included in accumulated other comprehensive loss.

Inventory, Net

Inventories are stated at the lower of cost or net realizable value, with cost computed on a first-in, first-out basis. The Company reduces the carrying value of inventories for items that are potentially excess, obsolete, or slow-moving based on changes in customer demand, technology developments, or other economic factors.

The Company capitalizes inventory produced for commercial sale. The Company capitalizes manufacturing costs as inventory following both the receipt of regulatory approval from regulatory bodies and the Company’s intent to commercialize. Costs associated with developmental products prior to satisfying the Company’s inventory capitalization criteria are charged to research and development expenses as incurred.

Products that have been approved by certain regulatory authorities may also be used in clinical programs to assess the safety and efficacy of the products for usage that have not been approved by the FDA or other regulatory authorities. The form of product utilized for both commercial and certain clinical programs that are identical are included as inventory with an “alternative future use” as defined in authoritative guidance. Component materials and purchased products associated with clinical development programs are included in inventory and charged to research and development expenses when the product enters the research and development process and no longer can be used for commercial purposes and, therefore, does not have an “alternative future use.”

For products that are under development and have not yet been approved by regulatory authorities, purchased component materials are charged to research and development expenses when the inventory ownership transfers to the Company.

The Company analyzes inventory levels to identify inventory that may expire prior to sale, inventory that has a cost basis in excess of its net realizable value, or inventory in excess of expected sales requirements. Although the manufacturing of the Company’s SNM systems is subject to strict quality control, certain batches or units of product may no longer meet quality specifications or may expire, which would require adjustments to the Company’s inventory values. The Company also applies judgment related to the results of quality tests that are performed throughout the production process, as well as the understanding of regulatory guidelines, to determine if it is probable that inventory will be saleable. These quality tests are performed throughout the pre- and post-production processes, and the Company continually gathers information regarding product quality for periods after the manufacturing date. The Company’s products currently have a maximum estimated shelf life range of 12 to 36 months and based on sales forecasts, the Company expects to realize the carrying value of the product inventory. In the future, reduced demand, quality issues, or excess supply beyond those anticipated by management may result in a material adjustment to inventory levels, which would be recorded as an increase to cost of sales.

The determination of whether inventory costs will be realizable or not requires estimates by the Company’s management. A critical input in this determination is future expected inventory requirements based on internal sales forecasts. Management then compares these requirements to the expiry dates of inventory on hand. To the extent that inventory is expected to expire prior to being sold, management will write down the value of inventory.

As of June 30, 2023, the Company had $37.9 million, $9.5 million and $22.7 million of finished goods inventory, work-in-process inventory and raw materials inventory, respectively, net of reserves of $0.9 million. As of December 31, 2022, the Company had $30.4 million, $5.7 million and $19.7 million of finished goods inventory, work-in-process inventory and raw materials inventory, respectively, net of reserves of $0.5 million.

Customer and Vendor Concentration

As of June 30, 2023 and December 31, 2022, there were no customers who accounted for over 10% of the Company’s consolidated accounts receivable. As of June 30, 2023 and December 31, 2022, there were three vendors and one vendor, respectively, who accounted for over 10% of the Company’s consolidated accounts payable. During the six months ended June 30, 2023 and 2022, there were no customers who accounted for over 10% of the Company’s consolidated net revenue. During the six months ended June 30, 2023 and 2022, there were three vendors and three vendors, respectively, who accounted for over 10% of the Company’s inventory-related purchases.

Property and Equipment

Property and equipment are stated at cost less accumulated depreciation. Depreciation is computed using the straight-line method over the estimated useful lives of the assets, generally between three and seven years. Leasehold improvements are amortized over the lesser of the life of the lease or the useful life of the improvements. Maintenance and repairs are charged to expense as incurred. When assets are retired or otherwise disposed of, the cost and accumulated depreciation are removed from the balance sheet and any resulting gain or loss is reflected in operations.

Goodwill

Goodwill represents the excess purchase price over the fair values of both tangible and intangible assets acquired less the liabilities assumed. Goodwill is tested for impairment at the reporting unit level by comparing the reporting unit’s carrying amount to the fair value of the reporting unit. The fair values are estimated using an income and discounted cash flow approach. The Company evaluates its goodwill on an annual basis in the fourth quarter or more frequently if it believes indicators of impairment exist. The Company assesses qualitative factors to determine whether it is more likely than not that the fair value of a reporting unit is less than its carrying amount or performs an annual impairment test. When tested quantitatively, the Company compares the fair value of the applicable reporting unit with its carrying value. In making this assessment, management relies on a number of factors, including expected future operating results, business plans, economic projections, anticipated future cash flows, business trends and declines in the Company’s market capitalization. The Company estimates the fair value of its reporting unit using a combination of the discounted cash flow and income approaches. If the carrying amount of a reporting unit exceeds the reporting unit’s fair value, the amount by which the carrying value exceeds the fair value is recognized as an impairment loss. During the six months ended June 30, 2023 and 2022, the Company did not record any impairment charges related to goodwill.

Intangible Assets

Patent license asset

The intangible asset represents exclusive rights to an additional field-of-use on the patent suite within the License Agreement with AMF. The additional field-of-use was provided in exchange for 50,000 shares of Series A preferred stock, the fair value of which was $1.0 million in 2013. The intangible asset was recorded at its fair value of $1.0 million at the date contributed. In connection with the initial public offering, such shares of Series A preferred stock were converted into common stock. Amortization of this asset is recorded over the shorter of the patent or legal life on a straight-line basis. The weighted-average amortization period is 8.71 years. The asset has been fully amortized as of June 30, 2023. For additional information, see Note 7.

Exclusive license asset

The intangible asset represents exclusive rights to existing technologies and development services from Micro Systems Engineering, Inc. pursuant to an agreement entered into on March 2, 2021. The rights and services were provided in exchange for 65,594 shares of common stock, the fair value of which was $3.6 million upon transfer. The intangible asset was recorded at its fair value of $3.3 million at the date of the agreement, with the difference of $0.3 million recorded as a vendor credit in accounts payable in the unaudited condensed consolidated balance sheets. Amortization of this asset is recorded over the four-year term of the agreement on a straight-line basis. The Company recorded expense for the amortization of the exclusive license asset of $0.2 million and $0.4 million during the three and six months ended June 30, 2023. The Company recorded expense for the amortization of the exclusive license asset of $0.2 million and $0.4 million during the three and six months ended

June 30, 2022. The Company will review the intangible asset for impairment whenever an impairment indicator exists. There have been no intangible asset impairment charges to date. For additional information, see Note 7.

Contura acquisition

The intangible assets represent technology, trade names and trademarks, and customer relationships acquired from Contura on February 25, 2021. The trade names and trademarks have an indefinite life. The straight-line method over the period of estimated benefit is used to amortize technology. ASC 350-30-35-3 states that customer relationships generally dissipate at a more rapid rate in the earlier periods following a company’s succession to these relationships, with the rate of attrition declining over time. As such, the accelerated method is used to amortize customer relationships. The Company recorded expense for the amortization of Contura acquisition intangible assets of $2.0 million and $4.1 million during the three and six months ended June 30, 2023, respectively. The Company recorded expense for the amortization of Contura acquisition intangible assets of $2.1 million and $4.3 million during the three and six months ended June 30, 2022, respectively. The Company reviewed the intangible assets for impairment for this asset group during the six months ended June 30, 2023. As Bulkamid SARL ceased sales operations and did not recognize revenue during the year ended December 31, 2022, and does not expect to recognize revenue in future periods, the Company wrote off the customer relationships intangible asset of $0.3 million related to this entity during the year ended December 31, 2022. The impairment expense is recorded within the general and administrative expenses in its unaudited condensed consolidated statements of comprehensive loss. For additional information, see Note 7.

Impairment of Long-Lived Assets

The Company reviews its long-lived assets for impairment whenever events or changes in circumstances indicate that the carrying amount of an asset may not be recoverable. Recoverability is measured by comparing the carrying amount to the future net cash flows that the assets are expected to generate. If said assets are considered to be impaired, the impairment that would be recognized is measured by the amount by which the carrying amount of the assets exceeds the projected discounted future net cash flows arising from the asset. There have been $0.3 million of impairments of long-lived assets to date.

Indefinite-lived intangible assets are tested for impairment annually in the fourth quarter of the fiscal year and whenever events or changes in circumstances indicate that the carrying amount may be impaired. Impairment is calculated as the excess of the asset’s carrying value over its fair value. Fair value is generally determined using a discounted future cash flow analysis. There have been no impairments to indefinite-lived intangible assets during the six months ended June 30, 2023.

Leases

In accordance with ASU No. 2016-02, “Leases (Topic 842),” components of a lease should be split into three categories: lease components, non-lease components, and non-components. The fixed and in-substance fixed contract consideration (including any consideration related to non-components) must be allocated based on the respective relative fair values to the lease components and non-lease components. Entities may elect not to separate lease and non-lease components. Rather, entities would account for each lease component and related non-lease component together as a single lease component. The Company has elected to account for lease and non-lease components together as a single lease component for all underlying assets and allocate all of the contract consideration to the lease component only. Topic 842 allows for the use of judgment in determining whether the assumed lease term is for a major part of the remaining economic life of the underlying asset and whether the present value of lease payments represents substantially all of the fair value of the underlying asset. The Company applies the bright line thresholds referenced in Topic 842 to assist in evaluating leases for appropriate classification between operating and finance leases. The aforementioned bright lines are applied consistently to the Company’s entire portfolio of leases.

Operating lease right-of-use (ROU) assets and operating lease liabilities are recognized based on the present value of the future minimum lease payments over the lease term at commencement date. As the Company’s leases do not provide an implicit rate, the Company uses its incremental borrowing rate, which is the rate for a fully collateralized amortizing loan with the same maturity as the lease term in similar economic environment, based on the information available at commencement date in determining the present value of future payments. The operating lease ROU assets also include any lease payments made and excludes lease incentives and initial direct costs

incurred. The lease terms may include options to extend or terminate the lease when it is reasonably certain that the Company will exercise that option. Lease expense for minimum lease payments is recognized on a straight-line basis over the lease term.

Research and Development

Research and development costs are charged to operations as incurred. Research and development costs include salary and personnel-related costs, costs of clinical studies and testing, royalty expense, supplies and materials, and outside consultant costs.

Advertising Expense

The Company expenses advertising costs as they are incurred. During the three and six months ended June 30, 2023, advertising expense totaled $4.1 million and $8.4 million, respectively, and are recorded within the sales and marketing expenses in its unaudited condensed consolidated statements of comprehensive loss. During the three and six months ended June 30, 2022, advertising expense totaled $6.3 million and $9.5 million, respectively, and are recorded within the sales and marketing expenses in its unaudited condensed consolidated statements of comprehensive loss.

Income Taxes

The Company accounts for income taxes using the asset and liability method to compute the difference between the tax basis of assets and liabilities and the related financial amounts, using currently enacted tax rates. The Company has net deferred tax assets in certain jurisdictions. The realization of these deferred tax assets is dependent upon the Company’s ability to generate sufficient taxable income in future years. Valuation allowances are established, when necessary, to reduce deferred tax assets to the amount that more likely than not will be realized. The Company evaluates the recoverability of the deferred tax assets annually, and maintains a full valuation allowance on its U.S. net deferred tax assets. The Company recognizes the tax benefit from an uncertain tax position only if it is more likely than not that the tax position will be sustained on examination by taxing authorities, based on the technical merits of the position. The Company is subject to transfer pricing and other tax regulations designed to ensure that appropriate levels of income are reported as earned by the Company’s U.S. and foreign entities and are taxed accordingly. In the normal course of business, the Company is audited by federal, state and foreign tax authorities, and subject to inquiries from those tax authorities regarding the amount of taxes due. These inquiries may relate to the timing and amount of deductions and the allocation of income among various tax jurisdictions. The Company’s policy is to recognize interest and penalties related to unrecognized tax benefits, if any, in income tax expense.

Stock-Based Compensation

The Company measures the cost of employee and non-employee services in exchange for an award of equity instruments based on the grant-date fair value of the award and recognizes compensation cost over the requisite service period (typically the vesting period), generally three or four years. Forfeitures are estimated at the time of the grant and revised in subsequent periods to reflect differences between the estimates and the number of shares that actually become exercisable.

The Company uses the Black-Scholes option pricing model to determine the fair value of stock options (as of the date of grant) that have service conditions for vesting. Stock options and restricted shares awards vest based on service conditions, typically over three or four years.

The Company also grants shares of performance-based restricted stock units that typically vest after one year only if the Company has also achieved certain performance objectives as defined and approved by the Company’s board of directors. The fair value of performance awards is determined based on the Company’s stock price at the date of grant and expensed over the performance period based on the probability of achieving the performance objectives. If such targets are not met or service is not rendered for the requisite service period, no compensation cost is recognized, and any recognized compensation cost in prior periods will be reversed. In addition, the Company also grants market-based restricted stock units that have combined market conditions and service conditions for vesting, for which the Company uses the Monte Carlo valuation model to value equity awards (as of the date of grant). Compensation cost is not adjusted if the market condition is not met, as long as the requisite service is provided.

Net Loss per Share of Common Stock

Basic net loss per share of common stock is calculated by dividing the net loss attributable to common stockholders by the weighted-average number of shares of common stock outstanding during the period, without consideration for potentially dilutive securities. Diluted net loss per share is computed by dividing the net loss attributable to common stockholders by the weighted-average number of shares of common stock and potentially dilutive securities outstanding for the period. For purposes of the diluted net loss per share calculation, common stock options, unvested RSAs and RSUs are considered to be potentially dilutive securities. Because the Company has reported a net loss in all periods presented, diluted net loss per share of common stock is the same as basic net loss per share of common stock for those periods.

For the three and six months ended June 30, 2023, there were 2,124,449 and 2,144,301 potentially dilutive weighted-average shares, respectively, that were not included in the computation of diluted weighted-average shares of common stock and common stock equivalent shares outstanding because their effect would have been antidilutive given the Company’s net loss. For the three and six months ended June 30, 2022, there were 2,403,317 and 2,414,973 potentially dilutive weighted-average shares, respectively, that were not included in the computation of diluted weighted-average shares of common stock and common stock equivalent shares outstanding because their effect would have been antidilutive given the Company’s net loss.

Segment Reporting

Operating segments are defined as components of an entity for which separate financial information is available and that is regularly reviewed by the Chief Operating Decision Maker (CODM) in deciding how to allocate resources to an individual segment and in assessing performance. The Company’s CODM is its Chief Executive Officer. The Company has determined it operates in one segment, the development and commercialization of innovative and minimally invasive products to treat bladder and bowel dysfunction. Geographically, the Company sells over 90% of its products to customers in the United States. Segment information is consistent with how management reviews the business, makes investing and resource allocation decisions and assesses operating performance.

Recent Accounting Pronouncements

We have reviewed and considered all recent accounting pronouncements that have not yet been adopted and believe there are none that could potentially have a material impact on our business practices, financial condition, results of operations, or disclosures.

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Property and Equipment, Net

6 Months Ended

Jun. 30, 2023

Property, Plant and Equipment [Abstract]

Property and Equipment, Net

Property and Equipment, Net

Property and equipment, net consists of the following (in thousands) at:

	June 30,		December 31,
	2023		2022
Equipment	$	2,782	$	2,645
Computer hardware and software	3,295		3,282
Tools and molds	2,225		1,735
Leasehold improvements	4,449		4,449
Furniture and fixtures	1,874		1,810
Construction in progress	794		413
	15,419		14,334
Less: accumulated depreciation and amortization	(9,070)		(7,536)
	$	6,349	$	6,798

Depreciation and amortization expense of property and equipment was $0.9 million and $1.5 million for the three and six months ended June 30, 2023, respectively. Depreciation and amortization expense of property and equipment was $0.5 million and $1.1 million for the three and six months ended June 30, 2022, respectively.

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Commitments and Contingencies

6 Months Ended

Jun. 30, 2023

Commitments and Contingencies Disclosure [Abstract]

Commitments and Contingencies

Commitments and Contingencies

Operating Leases

In August 2014, the Company entered into a five-year operating lease for approximately 12,215 square feet of office space beginning on November 1, 2014, and expiring on October 31, 2019. In June 2019, the lease was amended to extend the expiration date to October 31, 2020. In September 2020, the lease was amended to extend the expiration date to July 31, 2022. In December 2021, the lease was amended to extend the expiration date to January 31, 2028, and in April 2023, the lease was amended to reduce the expiration date to March 31, 2024. Upon the execution of the amendments, which were deemed to be a lease modification, the Company reassessed the lease liability using the incremental borrowing rate for a collateralized asset of the same remaining term at the modification date and adjusted the carrying amount of ROU assets by the amount of the remeasurement of the liability. The Company also reassessed the lease classification and concluded that the lease continues to be an operating lease. Under the terms of the lease, the Company is responsible for taxes, insurance, and maintenance expense. The lease contains certain scheduled rent increases. Rent expense is recognized on a straight-line basis over the expected lease term.

The Company entered into an operating lease for approximately 25,548 square feet of office space beginning on August 1, 2018, and expiring on October 31, 2027. In April 2023, the lease was amended to reduce the expiration date to December 31, 2024. Upon the execution of the amendment, which was deemed to be a lease modification, the Company reassessed the lease liability using the incremental borrowing rate for a collateralized asset of the same remaining term at the modification date and adjusted the carrying amount of ROU assets by the amount of the remeasurement of the liability. The Company also reassessed the lease classification and concluded that the lease continues to be an operating lease. Under the terms of the lease, the Company is responsible for taxes, insurance, and maintenance expense. The lease contains certain scheduled rent increases. Rent expense is recognized on a straight-line basis over the expected lease term. The Company has a renewal option to extend the term of the lease for a period of five years beyond the initial term. Under the terms of the lease, the base rent payable with respect to each renewal term will be equal to the prevailing market rental rent as of the commencement of the applicable renewal term. In the event of a default of certain of the Company’s obligations under the lease, the Company’s landlord would have the right to terminate the lease.

In June 2019, the Company entered into an eight-year operating lease for approximately 32,621 square feet of office space beginning on January 15, 2020 and expiring on January 31, 2028. In April 2023, the lease was amended to reduce the expiration date to March 31, 2024. Upon the execution of the amendment, which was deemed to be a lease modification, the Company reassessed the lease liability using the incremental borrowing rate for a collateralized asset of the same remaining term at the modification date and adjusted the carrying amount of ROU assets by the amount of the remeasurement of the liability. The Company also reassessed the lease classification and concluded that the lease continues to be an operating lease. The Company uses these premises as its new principal executive offices and for general office space. The Company is utilizing its other currently-leased spaces to conduct the training of its sales team and for manufacturing purposes. Under the terms of the lease, the Company is responsible for taxes, insurance, and maintenance expense. The lease contains certain scheduled rent increases. Rent expense is recognized on a straight-line basis over the expected lease term. The Company has a renewal option to extend the term of the lease for a period of five years beyond the initial term. Under the terms of the lease, the base rent payable with respect to each renewal term will be equal to the prevailing market rental rent as of the commencement of the applicable renewal term. In the event of a default of certain of the Company’s obligations under the lease, the Company’s landlord would have the right to terminate the lease.

In August 2020, the Company entered into a 38-month operating lease for approximately 5,693 square feet of warehouse space beginning on October 15, 2020 and expiring on December 31, 2023. In April 2023, the lease was amended to extend the expiration date to December 31, 2024. Upon the execution of the amendment, which was deemed to be a lease modification, the Company reassessed the lease liability using the incremental borrowing rate for a collateralized asset of the same remaining term at the modification date and adjusted the carrying amount of ROU assets by the amount of the remeasurement of the liability. The Company also reassessed the lease classification and concluded that the lease continues to be an operating lease. The Company uses these premises for general warehouse space.

In March 2022, the Company entered into an 18-month operating lease for approximately 3,276 square feet of warehouse space beginning on July 1, 2022 and expiring on December 31, 2023. In April 2023, the lease was amended to extend the expiration date to December 31, 2024. Upon the execution of the amendment, which was deemed to be a lease modification, the Company reassessed the lease liability using the incremental borrowing rate for a collateralized asset of the same remaining term at the modification date and adjusted the carrying amount of ROU assets by the amount of the remeasurement of the liability. The Company also reassessed the lease classification and concluded that the lease continues to be an operating lease. The Company uses these premises for general warehouse space.

In April 2023, the Company entered into a 120-month operating lease for approximately 145,960 square feet of office and warehouse space beginning on April 1, 2024 and expiring on March 31, 2034. The Company will use these premises as its new principal executive offices and for general office, manufacturing, and warehousing space. Under the terms of the lease, the Company is responsible for taxes, insurance, and maintenance expense. The lease contains certain scheduled rent increases. Rent expense is recognized on a straight-line basis over the expected lease term. The Company has a renewal option to extend the term of the lease for a period of five years beyond the initial term. Under the terms of the lease, the base rent payable with respect to each renewal term will be equal to the prevailing market rental rent as of the commencement of the applicable renewal term. In the event of a default of certain of the Company’s obligations under the lease, the Company’s landlord would have the right to terminate the lease. The Company has not taken possession or has been given control of this leased property as of June 30, 2023. Therefore, the Company has not recorded any ROU assets or operating lease liabilities related to this lease.

During the three and six months ended June 30, 2023, there were no ROU assets obtained in exchange for new operating lease liabilities. During the three and six months ended June 30, 2022, there were no ROU assets obtained in exchange for new operating lease liabilities. As of June 30, 2023 and December 31, 2022, the ROU assets had a balance of $0.7 million and $6.2 million, respectively. The operating lease ROU assets are included within the Company’s non-current other assets, and lease liabilities are included in current or noncurrent liabilities in the Company’s unaudited condensed consolidated balance sheets. During the three and six months ended June 30, 2023, cash paid for amounts included in operating lease liabilities was $0.5 million and $1.0 million, respectively. During the three and six months ended June 30, 2022, cash paid for amounts included in operating lease liabilities was $0.5 million and $1.0 million, respectively. Amortization of the ROU assets was $0.1 million and $0.4 million for the three and six months ended June 30, 2023, respectively. Amortization of the ROU assets was $0.3 million and $0.5 million for the three and six months ended June 30, 2022, respectively.

As of June 30, 2023 and December 31, 2022, the weighted-average remaining lease term for the Company’s operating leases was 1.2 years and 4.9 years, respectively. The weighted-average incremental borrowing rate for a collateralized asset of the same remaining term used to determine the present value of the Company’s operating leases’ future payments was 5.9% and 7.1%, respectively.

Total lease costs for the three and six months ended June 30, 2023 and 2022 are as follows (in thousands):

	Three Months Ended June 30,				Six Months Ended June 30,
	2023		2022		2023		2022
Lease cost
Operating lease cost	$	546	$	524	$	1,088	$	1,048
Short-term lease cost	22		20		45		41
Variable lease cost	178		132		285		257
Amortization of net lease liabilities	(656)		(94)		(723)		(184)
Total lease cost	$	90	$	582	$	695	$	1,162

License Agreement

In October 2013, the Company entered into the License Agreement, pursuant to which AMF, a Company stockholder, licensed the Company certain patents and know-how (collectively, the AMF IP) relating to, in relevant part, an implantable pulse generator and related system components in development by AMF as of that date, in

addition to any peripheral or auxiliary devices, including all components, that when assembled, comprise such device, excluding certain implantable pulse generators (collectively, the AMF Licensed Products). Under the License Agreement, for each calendar year beginning in 2018, the Company is obligated to pay AMF a royalty on an AMF Licensed Product-by-AMF Licensed Product basis if one of the following conditions applies: (i) one or more valid claims within any of the patents licensed to the Company by AMF covers such AMF Licensed Products or the manufacture of such AMF Licensed Products or (ii) for a period of 12 years from the first commercial sale anywhere in the world of such AMF Licensed Product, in each case. The foregoing royalty is calculated as the greater of (a) 4% of all net revenue derived from the AMF Licensed Products, and (b) the Minimum Royalty, payable quarterly. The Minimum Royalty automatically increases each year after 2018, subject to a maximum amount of $200,000 per year. The Company recorded related royalties of $0.8 million and $1.1 million during the three and six months ended June 30, 2023, respectively. The Company recorded related royalties of $0.6 million and $2.2 million during the three and six months ended June 30, 2022, respectively. Royalty expense is included in operating expenses in the unaudited condensed consolidated statements of comprehensive loss. Accrued royalties of $0.7 million and $0.6 million as of June 30, 2023 and December 31, 2022, respectively, are included within accrued liabilities in the Company’s unaudited condensed consolidated balance sheets. Royalty expense is declining because the Company’s F15 recharge-free SNM device is not covered by any AMF patents licensed to the Company and is therefore not an AMF Licensed Product that requires the payment of a royalty to AMF.

Legal Matters

The Company may, from time to time, become a party to legal proceedings. Such matters are subject to many uncertainties and to outcomes of which the financial impacts are not predictable with assurance and that may not be known for extended periods of time. When management has assessed that a loss is probable and an amount can be reasonably estimated, the Company records a liability.

On November 4, 2019, Medtronic, Inc., Medtronic Puerto Rico Operations Co., Medtronic Logistics LLC and Medtronic USA, Inc. (collectively, the Medtronic Affiliates) filed a complaint against the Company in the U.S. District Court for the Central District of California, Case No. 8:19-cv-2115, and amended the complaint on November 26, 2019. The Company refers to this matter as the Medtronic Litigation. The complaint asserts that the Company’s rechargeable SNM system infringes U.S. Patent Nos. 8,036,756, 8,626,314, 9,463,324 and 9,821,112 held by the Medtronic Affiliates, and the amended complaint further includes the additional patents 8,738,148; 8,457,758; and 7,774,069 (collectively, the Medtronic Patents). The Medtronic Litigation requests customary remedies for patent infringement, including (i) a judgment that the Company has infringed and is infringing the Medtronic Patents, (ii) damages, including treble damages for willful infringement, (iii) a permanent injunction preventing the Company from infringing the Medtronic Patents, (iv) attorneys’ fees, and (v) costs and expenses. The Company believes the allegations are without merit and is vigorously defending itself against them. The Company is unable to predict the likelihood of success of the claims of the Medtronic Affiliates against the Company or to quantify any risk of loss. The Medtronic Litigation could last for an extended period of time and require the Company to dedicate significant financial resources and management resources to its defense. An adverse ruling against the Company could materially and adversely affect its business, financial position, results of operations or cash flows and could also result in reputational harm. Even if the Company is successful in defending against these claims, the Medtronic Litigation could result in significant costs, delays in future product developments, reputational harm or other collateral consequences. The Federal Circuit recently reversed the decision of the Patent Trials & Appeals Board of the U.S. Patent & Trademark Office (PTAB) that the tined leads patents asserted against Axonics were valid, finding that the PTAB committed legal error in its analysis. The Federal Circuit remanded the matter to the PTAB for another review consistent with its opinion. Because of this development, the Court has issued a stay on the litigation proceedings, pending the outcome of the proceedings before the PTAB. As a result, the jury trial previously scheduled for August 2023 has been postponed.

AMF has alleged that the Company is in material breach of the License Agreement because it is not paying royalties on its F15 product, and AMF has claimed that it has terminated the License Agreement on that basis. The Company strongly disagrees that it is required to pay royalties on F15 or that AMF has the right to terminate the License Agreement. The Company has paid and will continue to pay 4% royalties on the rechargeable products launched to date. If the dispute between the parties cannot be settled amicably, the parties are obligated to go to arbitration. While a loss related to this claim is possible, the Company does not believe such loss is probable or estimable at this time.

In addition to the matters described above, the Company is and may continue to be involved in claims, legal proceedings, and investigations arising out of its operations in the normal course of business.

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Stock-Based Compensation

6 Months Ended

Jun. 30, 2023

Equity [Abstract]

Stock-Based Compensation

Stock-Based Compensation

Stock-based compensation expense included in the Company’s unaudited condensed consolidated statements of comprehensive loss is allocated as follows (in thousands):

	Three Months Ended June 30,				Six Months Ended June 30,
	2023		2022		2023		2022
Research and development	$	2,414	$	1,752	$	4,618	$	3,262
General and administrative	3,059		1,991		5,885		3,928
Sales and marketing	5,731		4,162		11,415		7,853
	$	11,204	$	7,905	$	21,918	$	15,043

Stock Option Activity

The option awards issued under the 2014 Stock Option Plan (the 2014 Plan) and the 2018 Omnibus Incentive Plan (the 2018 Plan) were measured based on fair value. The Company used the simplified method of determining the expected term of stock options as the Company believes this represents the best estimate of the expected term of a new option. The expected stock price volatility assumption was determined by examining the historical volatilities for industry peers, as the Company did not have sufficient trading history for the Company’s common stock. The Company will continue to analyze the historical stock price volatility and expected term assumption as more historical data for the Company’s common stock becomes available. The risk-free interest rate assumption is based on the U.S. Treasury instruments, whose term was consistent with the expected term of the Company’s stock options. The expected dividend assumption is based on the Company’s history and expectation of dividend payouts. The assumptions regarding the expected term of the options and the expected volatility of the stock price are subjective, and these assumptions have a significant effect on the estimated fair value amounts. There were no stock option grants for the three and six months ended June 30, 2023 and 2022.

As of June 30, 2023 and December 31, 2022, there was $0.7 million and $1.8 million, respectively, of total unrecognized compensation cost related to unvested stock options that is expected to be recognized over a weighted-average period of approximately 0.8 years and 1.0 year, respectively.

The following table summarizes stock option activity for the six months ended June 30, 2023 under the 2014 and 2018 Plans (in thousands, except share and per share data):

	Number of Options	Weighted-Average Exercise Price Per Share		Aggregate Intrinsic Value
Outstanding at December 31, 2022	1,046,610	$	18.81
Options exercised	(159,681)	17.50		$	6,978	(1)
Options forfeited	(585)	29.71
Outstanding at June 30, 2023	886,344	$	19.03	$	28,118	(2)

_____________________________________________

(1)    Represents the total difference between the Company’s closing stock price at the time of exercise and the stock option exercise price, multiplied by the number of options exercised.

(2)    Represents the total difference between the Company’s closing stock price on the last trading day of the second quarter of 2023 and the stock option exercise price, multiplied by the number of in-the-money options as of June 30, 2023. The amount of intrinsic value will change based on the fair market value of the Company’s stock.

The weighted-average remaining contractual term of options outstanding and exercisable was 5.7 years and 6.1 years at June 30, 2023 and December 31, 2022, respectively.

Restricted Shares Awards Activity

As of June 30, 2023 and December 31, 2022, there was $56.8 million and $54.0 million, respectively, of total unrecognized compensation cost related to unvested restricted shares awards that is expected to be recognized over a weighted-average period of approximately 2.1 years and 2.3 years, respectively.

The following table summarizes restricted shares awards activity for the six months ended June 30, 2023:

	Number of Restricted Shares Awards	Weighted-Average Fair Value Per Share at Grant Date
Outstanding at December 31, 2022	1,320,866	$	52.23
Restricted shares awards granted	349,866	57.11
Restricted shares awards vested	(342,907)	43.28
Restricted shares awards forfeited	(59,518)	55.23
Outstanding at June 30, 2023	1,268,307	$	55.86

Restricted Stock Units Activity

As of June 30, 2023 and December 31, 2022, there was $11.4 million and $1.3 million, respectively, of total unrecognized compensation cost related to unvested restricted stock units that is expected to be recognized over a weighted-average period of approximately 1.0 year and 0.8 years, respectively.

The following table summarizes restricted stock units activity for the six months ended June 30, 2023:

	Number of Restricted Stock Units	Weighted-Average Fair Value Per Share at Grant Date
Outstanding at December 31, 2022	183,418	$	48.74
Restricted stock units granted	286,750	65.44
Restricted stock units vested	(199,718)	49.84
Outstanding at June 30, 2023	270,450	$	70.10

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Income Taxes

6 Months Ended

Jun. 30, 2023

Income Tax Disclosure [Abstract]

Income Taxes

Income Taxes

The following table presents details of the provision for income taxes and effective tax rates (in thousands, except percentages):

	Three Months Ended June 30,		Six Months Ended June 30,
	2023	2022	2023	2022
Income tax benefit	$(304)	$(465)	$(1,111)	$(1,576)
Effective tax rate	3.97%	2.13%	6.27%	3.45%

The Company accounts for income taxes according to ASC 740, “Income Taxes.” The Company periodically evaluates whether a portion or all of its deferred tax assets will be recovered. The Company records a valuation allowance against deferred tax assets if and to the extent it is more likely than not that they will not be recovered. In evaluating the need for a valuation allowance, the Company weighs all relevant positive and negative evidence, including among other factors, historical financial performance, forecasts of income over the applicable carryforward periods, and the market environment, with each consideration weighted based on its reliability. The Company continues to maintain a full valuation allowance against its otherwise recognizable U.S. net deferred income tax assets as of June 30, 2023 and December 31, 2022.

The effective tax rate differs from the statutory U.S. income tax rate due to differing tax rates imposed on income earned in foreign jurisdictions, losses in foreign jurisdictions, and certain nondeductible expenses. The effective tax rate could change significantly from quarter to quarter because of recurring and nonrecurring factors. The provision for income taxes for the six months ended June 30, 2023 was primarily the result of losses benefited in certain foreign jurisdictions.

At December 31, 2022, the Company had U.S. federal and foreign net operating loss (NOL) carryforwards of approximately $270.3 million and $9.6 million, respectively. U.S. federal NOLs in the amount of $51.5 million will expire between 2033 and 2037 while the remainder will carryover indefinitely. The foreign net operating loss carryforwards have an indefinite carryforward period. The Company had U.S. state NOLs of $254.6 million, which will expire between 2033 and 2042. Interest and penalties related to income tax matters are recorded in income tax expense (benefit) in the condensed consolidated statements of comprehensive loss and the related liability is recorded in accrued liabilities in the condensed consolidated balance sheets, as applicable.

Pursuant to Sections 382 and 383 of the Internal Revenue Code of 1986, as amended (the Internal Revenue Code), use of the Company’s NOL carryforwards may be limited if the Company experiences a cumulative change in ownership of greater than 50% in a rolling three-year period. The Company performed an analysis of changes in ownership for purposes of these Internal Revenue Code sections. Based on the study performed in 2020, the

Company determined that an ownership change occurred in 2014, 2018 and 2019. The total reduction of the net operating loss carryforwards was offset by valuation allowance, and there was no impact to tax expense related to the limitation. Based on the study performed in 2022 and 2021, the Company determined that an ownership change did not occur in 2022 and 2021. Future ownership changes could impact the Company’s ability to utilize NOL carryforwards.

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Employee Benefit Plan	6 Months Ended
	Jun. 30, 2023
Retirement Benefits [Abstract]
Employee Benefit Plan	Employee Benefit PlanThe Company sponsors a defined contribution retirement savings plan under Section 401(k) of the Internal Revenue Code. This plan covers all U.S. employees who meet minimum age and service requirements, and allows participants to defer a portion of their annual compensation on a pre- or post-tax basis. Contributions to the plan by the Company may be made at the discretion of the board of directors. During the three and six months ended June 30, 2023, the Company contributions to the plan amounted to $0.6 million and $1.2 million, respectively. During the three and six months ended June 30, 2022, the Company contributions to the plan amounted to $0.5 million and $1.0 million, respectively.

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Goodwill and Intangible Assets

6 Months Ended

Jun. 30, 2023

Goodwill and Intangible Assets Disclosure [Abstract]

Goodwill and Intangible Assets

Goodwill and Intangible Assets

The change in the carrying amount of goodwill during the six months ended June 30, 2023 included the following (in thousands):

December 31, 2022	$	94,414
Foreign currency translation adjustment	4,466
June 30, 2023	$	98,880

Intangible assets as of June 30, 2023 included the following (in thousands):

		June 30, 2023
	Weighted-Average Amortization Period	Gross Carrying Amount		Accumulated Amortization		Impairment		Foreign currency translation adjustment		Intangible Assets, Net
Patent license asset	8.71 years	$	1,000	$	(1,000)	$	—	$	—	$	—
Exclusive license asset	4 years	3,300		(1,980)		—		—		1,320
Technology	12 years	81,100		(15,863)		—		(6,380)		58,857
Trade names and trademarks	Indefinite	19,700		—		—		(1,580)		18,120
Customer relationships	12 years	11,400		(3,087)		(287)		(780)		7,246
		$	116,500	$	(21,930)	$	(287)	$	(8,740)	$	85,543

Intangible assets as of December 31, 2022 included the following (in thousands):

		December 31, 2022
	Weighted-Average Amortization Period	Gross Carrying Amount		Accumulated Amortization		Impairment		Foreign currency translation adjustment		Intangible Asset, Net
Patent license asset	8.71 years	$	1,000	$	(1,000)	$	—	$	—	$	—
Exclusive license asset	4 years	3,300		(1,540)		—		—		1,760
Technology	12 years	81,100		(12,496)		—		(9,141)		59,463
Trade names and trademarks	Indefinite	19,700		—		—		(2,398)		17,302
Customer relationships	12 years	11,400		(2,393)		(287)		(992)		7,728
		$	116,500	$	(17,429)	$	(287)	$	(12,531)	$	86,253

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Nature of Operations and Summary of Significant Accounting Policies (Policies)

6 Months Ended

Jun. 30, 2023

Organization, Consolidation and Presentation of Financial Statements [Abstract]

Principles of Consolidation

Principles of Consolidation

The accompanying unaudited interim condensed consolidated financial statements include the accounts of the Company and its wholly-owned subsidiaries: Axonics Europe, S.A.S., Axonics Modulation Technologies U.K. Limited, Axonics Modulation Technologies Australia Pty Ltd, Axonics Women’s Health Limited, Bulkamid SARL, Axonics GmbH, and Contura, Inc. Intercompany accounts and transactions have been eliminated in consolidation.

Basis of Presentation and Liquidity

Basis of Presentation and Liquidity

Interim Financial Statements

The unaudited interim condensed consolidated financial statements and related footnote disclosures as of and for the three and six months ended June 30, 2023 are unaudited, and are not necessarily indicative of the Company’s operating results for a full year. The unaudited interim condensed consolidated financial statements include all normal and recurring adjustments necessary for a fair presentation of the Company’s financial results for the three and six months ended June 30, 2023 in accordance with United States generally accepted accounting principles (GAAP), however, certain information and footnote disclosures normally included in annual financial statements prepared in accordance with GAAP have been condensed or omitted pursuant to the U.S. Securities and Exchange Commission (SEC) rules and regulations relating to interim financial statements. The accompanying unaudited condensed consolidated financial statements should be read in conjunction with the Company’s audited consolidated financial statements and notes thereto included within the Company’s Annual Report on Form 10-K for the fiscal year ended December 31, 2022 (filed with the SEC on March 1, 2023).

Use of Estimates

Use of Estimates

The preparation of unaudited condensed consolidated financial statements in conformity with GAAP requires the Company’s management to make estimates and judgments that affect the reported amounts of assets, liabilities, and expenses, and related disclosures of contingent assets and liabilities. The Company bases its estimates on historical experience and on various other assumptions that it believes to be reasonable under the circumstances. The results of this evaluation then form the basis for making judgments about the carrying values of assets and liabilities that are not readily apparent from other sources. Actual results may differ from these estimates, and such differences may be material to the consolidated financial statements. Significant items subject to such estimates and assumptions include the useful lives of property and equipment and intangible assets, the valuation of deferred income tax assets and liabilities, the valuation of contingent consideration liability, the valuation of stock-based compensation, the product returns reserve, the inventory obsolescence reserve and accounts receivable allowance for credit losses.

Revenue Recognition

Revenue Recognition

Revenue recognized during the six months ended June 30, 2023 and 2022 relates entirely to the sale of the Company’s products to its customers and distributors.

The Company has revenue arrangements that consist of a single performance obligation. The Company recognizes revenue at the point in time when it transfers control of promised goods to its customers. Revenue is measured as the amount of consideration expected to be received in exchange for transferring goods. The amount of revenue that is recognized is based on the transaction price, which represents the invoiced amount and includes estimates of variable consideration such as discounts, where applicable. The Company also sells to distributors and applies the same policies as its revenue arrangements with customers, specifically that revenue is recognized at the point in time when it transfers control of promised goods to its distributors. The Company does not offer rights of return or price protection. The amount of variable consideration included in the transaction price may be constrained and is included only to the extent that it is probable that a significant reversal in the amount of the cumulative revenue recognized under the contract will not occur in a future period. Payment terms, typically less than three months, do not include a significant financing component. The Company extends credit to its customers and distributors based upon an evaluation of their financial condition and credit history and generally requires no collateral. The Company does not have any contract balances related to product sales. The Company also does not have significant contract acquisition costs related to product sales.

In accordance with Company policy and based on the Company’s historical experience, the allowance for product returns was $0.2 million and $0.2 million at June 30, 2023 and December 31, 2022, respectively, and is recorded as a reduction of gross revenue in its unaudited condensed consolidated statements of comprehensive loss. Damaged or defective products are replaced at no charge under the Company’s standard warranty. For the three and six months ended June 30, 2023, the replacement costs were minimal and $0.1 million, respectively. For the three and six months ended June 30, 2022, the replacement costs were minimal and $0.1 million, respectively. The replacement costs are recorded within the sales and marketing expenses in its unaudited condensed consolidated statements of comprehensive loss.

The Company offers its standard warranty to all customers. The Company does not sell any warranties on a standalone basis. The Company’s warranty provides that its products are free of material defects and conform to specifications, and includes an offer to repair, replace or refund the purchase price of defective products. This assurance does not constitute a service and is not considered a separate performance obligation. The Company estimates warranty liabilities at the time of revenue recognition and records it as a charge to sales and marketing expense. The warranty liability as of June 30, 2023 and December 31, 2022 was $0.1 million and $0.1 million, respectively.

Shipping and handling costs incurred for the delivery of goods to customers and distributors are included in cost of goods sold. Amounts billed to customers and distributors for shipping and handling are included in net revenue.

Allowance for Credit Losses

Allowance for Credit Losses

The Company makes estimates of the collectability of accounts receivable in accordance with Accounting Standards Update (ASU) 2016-13, “Financial Instruments—Credit Losses (Topic 326): Measurement of Credit Losses on Financial Instruments.” The Company’s estimate of future credit losses is made by management based upon historical bad debts, customer receivable balances, age of customer receivable balances, customers’ financial conditions and reasonable forecasted economic trends. Despite the Company’s efforts to minimize credit risk exposure, customers could be adversely affected if future economic and industry trends change in such a manner as to negatively impact their cash flows. As a result, the Company’s future collection experience can differ significantly from historical collection trends. If the Company’s customers experience a negative impact on their cash flows, it could have a material adverse effect on the Company’s results of operations and financial condition.

Cash and Cash Equivalents

Cash and Cash Equivalents

Cash equivalents consist of short-term, highly liquid investments purchased with a maturity of three months or less. Financial instruments that potentially subject the Company to a concentration of credit risk consist of cash and cash equivalents. At times, the cash and cash equivalent balances may exceed federally insured limits. The Company does not believe that this results in any significant credit risk as the Company’s policy is to place its cash and cash equivalents in highly-rated financial institutions. The Company also holds cash in foreign banks that are not federally insured. The Company has not experienced any losses on its deposits of cash and cash equivalents.

Fair Value of Financial Instruments

Fair Value of Financial Instruments

Fair value is defined as the price that would be received to sell an asset or paid to transfer a liability in an orderly transaction between market participants at the measurement date. A three-level fair value hierarchy prioritizes the inputs used to measure fair value. The hierarchy requires entities to maximize the use of observable inputs and minimize the use of unobservable inputs. The three levels of inputs used to measure fair value are as follows:

•Level 1: Inputs are unadjusted quoted prices in active markets for identical assets or liabilities.

•Level 2: Inputs are quoted prices for similar assets and liabilities in active markets or quoted prices for identical or similar instruments in markets that are not active and model-derived valuations in which all significant inputs and significant value drivers are observable in active markets.

•Level 3: Inputs are unobservable inputs based on the Company’s assumptions and valuation techniques used to measure assets and liabilities at fair value. The inputs require significant management judgment or estimation.

Level 1 investments include U.S. government and agency securities, which are valued based on prices readily available in the active markets in which those securities are traded. Level 2 investments include commercial paper and corporate notes, which is valued on a recurring basis based on inputs that are readily available in public markets or can be derived from information available in publicly quoted markets.

The Company’s assessment of the significance of an input to the fair value measurement requires judgment, which may affect the valuation of fair value assets and liabilities and their placement within the fair value hierarchy levels. The carrying amounts reported in the unaudited condensed consolidated financial statements approximate the fair value for cash and cash equivalents, accounts receivable, and accounts payables, due to their short-term nature.

The purchase price of business acquisitions is primarily allocated to the tangible and identifiable intangible assets acquired and liabilities assumed based on their estimated fair values on the acquisition date, with the excess recorded as goodwill.

Certain of the Company’s business combinations involve potential payment of future consideration that is contingent upon the achievement of certain product development milestones and/or contingent on the acquired business reaching certain performance milestones. A liability is recorded for the estimated fair value of the contingent consideration on the acquisition date. The fair value of the contingent consideration is remeasured at each reporting period, and the change in fair value is recognized within operating expenses in the consolidated statements of comprehensive loss.

On February 25, 2021, the Company acquired Contura Limited and its Bulkamid product, a urethral bulking agent indicated for the treatment of female SUI. In consideration for the acquisition, the Company paid approximately $141.3 million in cash and issued 1,096,583 shares of our common stock. The agreement also provided that the Company may pay an additional $35 million in the event Bulkamid sales in any consecutive 12-month period exceed $50 million (the Milestone) before December 31, 2024, with payment due within 50 business days following the quarter in which the Milestone has been met.

Contingent consideration represents contingent milestone, performance and revenue-sharing payment obligations related to acquisitions and is measured at fair value, based on significant inputs not observable in the market, which represents a Level 3 measurement within the fair value hierarchy. The valuation of contingent consideration is estimated using a binary option-based approach with assumptions the Company believes would be made by a market participant. Significant inputs include projected revenues, discount rates, volatility factors and risk-free rates. The Company assesses these assumptions on an ongoing basis as additional data impacting the assumptions is obtained and any change in fair value of the contingent consideration is recorded within acquisition-related costs in the consolidated statements of comprehensive loss. Significant increases or decreases in any of those inputs in isolation would result in a significantly lower or higher fair value measurement. Generally, a change in the assumption used for the projected revenues would result in a directionally similar change to the overall estimate of the contingent consideration.

Investment Securities

Investment Securities

The Company classifies its investment securities as available-for-sale. Those investments in debt securities with maturities less than 12 months at the balance sheet date are considered short-term investments. Those investments in debt securities with maturities greater than 12 months at the balance sheet date are considered long-term investments. The Company’s investment securities classified as available-for-sale are recorded at fair value based on the fair value hierarchy (Level 1 and Level 2 inputs in the fair value hierarchy), and consists primarily of commercial paper, corporate notes and U.S. government and agency securities. Unrealized gains or losses, deemed temporary in nature, are reported as other comprehensive income (loss) within the unaudited condensed consolidated statements of comprehensive loss. There were no unrealized gains or losses during the three and six months ended June 30, 2023 and 2022.

A decline in the fair value of any security below cost that is deemed other than temporary results in a charge to net income (loss) and the corresponding establishment of a credit loss allowance for the security. Premiums (discounts) are amortized (accreted) over the life of the related security as an adjustment to yield using the straight-line interest method. Dividend, accretion and interest income are recognized when earned. Realized gains or losses are included in net loss and are derived using the specific identification method for determining the cost of securities sold.

The Company holds investments in marketable debt securities that are classified and accounted for as cash equivalents or available-for-sale and are remeasured on a recurring basis. All of the Company’s available-for-sale debt securities are classified on the unaudited condensed consolidated balance sheets as cash equivalents or short-term investments.

Foreign Currency Translation

Foreign Currency Translation

The functional currencies of the Company’s subsidiaries are currencies other than the U.S. dollar. The Company translates assets and liabilities of the foreign subsidiaries into U.S. dollars at the exchange rate in effect on the balance sheet date. Revenue and expenses of the subsidiaries are translated into U.S. dollars at the average exchange rate during the period. Gains or losses from these translation adjustments are reported as a separate component of stockholders’ equity in accumulated other comprehensive gain or loss until there is a sale or complete or substantially complete liquidation of the Company’s investment in the foreign subsidiary at which time the gains or losses will be realized and included in net income (loss). As of June 30, 2023 and December 31, 2022, all foreign currency translation gains (losses) have been unrealized and included in accumulated other comprehensive loss.

Inventory, Net

Inventory, Net

Inventories are stated at the lower of cost or net realizable value, with cost computed on a first-in, first-out basis. The Company reduces the carrying value of inventories for items that are potentially excess, obsolete, or slow-moving based on changes in customer demand, technology developments, or other economic factors.

The Company capitalizes inventory produced for commercial sale. The Company capitalizes manufacturing costs as inventory following both the receipt of regulatory approval from regulatory bodies and the Company’s intent to commercialize. Costs associated with developmental products prior to satisfying the Company’s inventory capitalization criteria are charged to research and development expenses as incurred.

Products that have been approved by certain regulatory authorities may also be used in clinical programs to assess the safety and efficacy of the products for usage that have not been approved by the FDA or other regulatory authorities. The form of product utilized for both commercial and certain clinical programs that are identical are included as inventory with an “alternative future use” as defined in authoritative guidance. Component materials and purchased products associated with clinical development programs are included in inventory and charged to research and development expenses when the product enters the research and development process and no longer can be used for commercial purposes and, therefore, does not have an “alternative future use.”

For products that are under development and have not yet been approved by regulatory authorities, purchased component materials are charged to research and development expenses when the inventory ownership transfers to the Company.

The Company analyzes inventory levels to identify inventory that may expire prior to sale, inventory that has a cost basis in excess of its net realizable value, or inventory in excess of expected sales requirements. Although the manufacturing of the Company’s SNM systems is subject to strict quality control, certain batches or units of product may no longer meet quality specifications or may expire, which would require adjustments to the Company’s inventory values. The Company also applies judgment related to the results of quality tests that are performed throughout the production process, as well as the understanding of regulatory guidelines, to determine if it is probable that inventory will be saleable. These quality tests are performed throughout the pre- and post-production processes, and the Company continually gathers information regarding product quality for periods after the manufacturing date. The Company’s products currently have a maximum estimated shelf life range of 12 to 36 months and based on sales forecasts, the Company expects to realize the carrying value of the product inventory. In the future, reduced demand, quality issues, or excess supply beyond those anticipated by management may result in a material adjustment to inventory levels, which would be recorded as an increase to cost of sales.

The determination of whether inventory costs will be realizable or not requires estimates by the Company’s management. A critical input in this determination is future expected inventory requirements based on internal sales forecasts. Management then compares these requirements to the expiry dates of inventory on hand. To the extent that inventory is expected to expire prior to being sold, management will write down the value of inventory.

Property and Equipment

Property and Equipment

Property and equipment are stated at cost less accumulated depreciation. Depreciation is computed using the straight-line method over the estimated useful lives of the assets, generally between three and seven years. Leasehold improvements are amortized over the lesser of the life of the lease or the useful life of the improvements. Maintenance and repairs are charged to expense as incurred. When assets are retired or otherwise disposed of, the cost and accumulated depreciation are removed from the balance sheet and any resulting gain or loss is reflected in operations.

Goodwill

GoodwillGoodwill represents the excess purchase price over the fair values of both tangible and intangible assets acquired less the liabilities assumed. Goodwill is tested for impairment at the reporting unit level by comparing the reporting unit’s carrying amount to the fair value of the reporting unit. The fair values are estimated using an income and discounted cash flow approach. The Company evaluates its goodwill on an annual basis in the fourth quarter or more frequently if it believes indicators of impairment exist. The Company assesses qualitative factors to determine whether it is more likely than not that the fair value of a reporting unit is less than its carrying amount or performs an annual impairment test. When tested quantitatively, the Company compares the fair value of the applicable reporting unit with its carrying value. In making this assessment, management relies on a number of factors, including expected future operating results, business plans, economic projections, anticipated future cash flows, business trends and declines in the Company’s market capitalization. The Company estimates the fair value of its reporting unit using a combination of the discounted cash flow and income approaches. If the carrying amount of a reporting unit exceeds the reporting unit’s fair value, the amount by which the carrying value exceeds the fair value is recognized as an impairment loss.

Intangible Assets

Intangible Assets

Patent license asset

The intangible asset represents exclusive rights to an additional field-of-use on the patent suite within the License Agreement with AMF. The additional field-of-use was provided in exchange for 50,000 shares of Series A preferred stock, the fair value of which was $1.0 million in 2013. The intangible asset was recorded at its fair value of $1.0 million at the date contributed. In connection with the initial public offering, such shares of Series A preferred stock were converted into common stock. Amortization of this asset is recorded over the shorter of the patent or legal life on a straight-line basis. The weighted-average amortization period is 8.71 years. The asset has been fully amortized as of June 30, 2023. For additional information, see Note 7.

Exclusive license asset

The intangible asset represents exclusive rights to existing technologies and development services from Micro Systems Engineering, Inc. pursuant to an agreement entered into on March 2, 2021. The rights and services were provided in exchange for 65,594 shares of common stock, the fair value of which was $3.6 million upon transfer. The intangible asset was recorded at its fair value of $3.3 million at the date of the agreement, with the difference of $0.3 million recorded as a vendor credit in accounts payable in the unaudited condensed consolidated balance sheets. Amortization of this asset is recorded over the four-year term of the agreement on a straight-line basis. The Company recorded expense for the amortization of the exclusive license asset of $0.2 million and $0.4 million during the three and six months ended June 30, 2023. The Company recorded expense for the amortization of the exclusive license asset of $0.2 million and $0.4 million during the three and six months ended

June 30, 2022. The Company will review the intangible asset for impairment whenever an impairment indicator exists. There have been no intangible asset impairment charges to date. For additional information, see Note 7.

Contura acquisition

The intangible assets represent technology, trade names and trademarks, and customer relationships acquired from Contura on February 25, 2021. The trade names and trademarks have an indefinite life. The straight-line method over the period of estimated benefit is used to amortize technology. ASC 350-30-35-3 states that customer relationships generally dissipate at a more rapid rate in the earlier periods following a company’s succession to these relationships, with the rate of attrition declining over time. As such, the accelerated method is used to amortize customer relationships. The Company recorded expense for the amortization of Contura acquisition intangible assets of $2.0 million and $4.1 million during the three and six months ended June 30, 2023, respectively. The Company recorded expense for the amortization of Contura acquisition intangible assets of $2.1 million and $4.3 million during the three and six months ended June 30, 2022, respectively. The Company reviewed the intangible assets for impairment for this asset group during the six months ended June 30, 2023. As Bulkamid SARL ceased sales operations and did not recognize revenue during the year ended December 31, 2022, and does not expect to recognize revenue in future periods, the Company wrote off the customer relationships intangible asset of $0.3 million related to this entity during the year ended December 31, 2022. The impairment expense is recorded within the general and administrative expenses in its unaudited condensed consolidated statements of comprehensive loss. For additional information, see Note 7.

Impairment of Long-Lived Assets

Impairment of Long-Lived Assets

The Company reviews its long-lived assets for impairment whenever events or changes in circumstances indicate that the carrying amount of an asset may not be recoverable. Recoverability is measured by comparing the carrying amount to the future net cash flows that the assets are expected to generate. If said assets are considered to be impaired, the impairment that would be recognized is measured by the amount by which the carrying amount of the assets exceeds the projected discounted future net cash flows arising from the asset. There have been $0.3 million of impairments of long-lived assets to date.

Indefinite-lived intangible assets are tested for impairment annually in the fourth quarter of the fiscal year and whenever events or changes in circumstances indicate that the carrying amount may be impaired. Impairment is calculated as the excess of the asset’s carrying value over its fair value. Fair value is generally determined using a discounted future cash flow analysis. There have been no impairments to indefinite-lived intangible assets during the six months ended June 30, 2023.

Leases

Leases

In accordance with ASU No. 2016-02, “Leases (Topic 842),” components of a lease should be split into three categories: lease components, non-lease components, and non-components. The fixed and in-substance fixed contract consideration (including any consideration related to non-components) must be allocated based on the respective relative fair values to the lease components and non-lease components. Entities may elect not to separate lease and non-lease components. Rather, entities would account for each lease component and related non-lease component together as a single lease component. The Company has elected to account for lease and non-lease components together as a single lease component for all underlying assets and allocate all of the contract consideration to the lease component only. Topic 842 allows for the use of judgment in determining whether the assumed lease term is for a major part of the remaining economic life of the underlying asset and whether the present value of lease payments represents substantially all of the fair value of the underlying asset. The Company applies the bright line thresholds referenced in Topic 842 to assist in evaluating leases for appropriate classification between operating and finance leases. The aforementioned bright lines are applied consistently to the Company’s entire portfolio of leases.

Operating lease right-of-use (ROU) assets and operating lease liabilities are recognized based on the present value of the future minimum lease payments over the lease term at commencement date. As the Company’s leases do not provide an implicit rate, the Company uses its incremental borrowing rate, which is the rate for a fully collateralized amortizing loan with the same maturity as the lease term in similar economic environment, based on the information available at commencement date in determining the present value of future payments. The operating lease ROU assets also include any lease payments made and excludes lease incentives and initial direct costs

incurred. The lease terms may include options to extend or terminate the lease when it is reasonably certain that the Company will exercise that option. Lease expense for minimum lease payments is recognized on a straight-line basis over the lease term.

Research and Development

Research and Development

Research and development costs are charged to operations as incurred. Research and development costs include salary and personnel-related costs, costs of clinical studies and testing, royalty expense, supplies and materials, and outside consultant costs.

Advertising Expense

Advertising ExpenseThe Company expenses advertising costs as they are incurred.

Income Taxes

Income Taxes

The Company accounts for income taxes using the asset and liability method to compute the difference between the tax basis of assets and liabilities and the related financial amounts, using currently enacted tax rates. The Company has net deferred tax assets in certain jurisdictions. The realization of these deferred tax assets is dependent upon the Company’s ability to generate sufficient taxable income in future years. Valuation allowances are established, when necessary, to reduce deferred tax assets to the amount that more likely than not will be realized. The Company evaluates the recoverability of the deferred tax assets annually, and maintains a full valuation allowance on its U.S. net deferred tax assets. The Company recognizes the tax benefit from an uncertain tax position only if it is more likely than not that the tax position will be sustained on examination by taxing authorities, based on the technical merits of the position. The Company is subject to transfer pricing and other tax regulations designed to ensure that appropriate levels of income are reported as earned by the Company’s U.S. and foreign entities and are taxed accordingly. In the normal course of business, the Company is audited by federal, state and foreign tax authorities, and subject to inquiries from those tax authorities regarding the amount of taxes due. These inquiries may relate to the timing and amount of deductions and the allocation of income among various tax jurisdictions. The Company’s policy is to recognize interest and penalties related to unrecognized tax benefits, if any, in income tax expense.

Stock-Based Compensation

Stock-Based Compensation

The Company measures the cost of employee and non-employee services in exchange for an award of equity instruments based on the grant-date fair value of the award and recognizes compensation cost over the requisite service period (typically the vesting period), generally three or four years. Forfeitures are estimated at the time of the grant and revised in subsequent periods to reflect differences between the estimates and the number of shares that actually become exercisable.

The Company uses the Black-Scholes option pricing model to determine the fair value of stock options (as of the date of grant) that have service conditions for vesting. Stock options and restricted shares awards vest based on service conditions, typically over three or four years.

The Company also grants shares of performance-based restricted stock units that typically vest after one year only if the Company has also achieved certain performance objectives as defined and approved by the Company’s board of directors. The fair value of performance awards is determined based on the Company’s stock price at the date of grant and expensed over the performance period based on the probability of achieving the performance objectives. If such targets are not met or service is not rendered for the requisite service period, no compensation cost is recognized, and any recognized compensation cost in prior periods will be reversed. In addition, the Company also grants market-based restricted stock units that have combined market conditions and service conditions for vesting, for which the Company uses the Monte Carlo valuation model to value equity awards (as of the date of grant). Compensation cost is not adjusted if the market condition is not met, as long as the requisite service is provided.

Net Loss per Share of Common Stock

Net Loss per Share of Common Stock

Basic net loss per share of common stock is calculated by dividing the net loss attributable to common stockholders by the weighted-average number of shares of common stock outstanding during the period, without consideration for potentially dilutive securities. Diluted net loss per share is computed by dividing the net loss attributable to common stockholders by the weighted-average number of shares of common stock and potentially dilutive securities outstanding for the period. For purposes of the diluted net loss per share calculation, common stock options, unvested RSAs and RSUs are considered to be potentially dilutive securities. Because the Company has reported a net loss in all periods presented, diluted net loss per share of common stock is the same as basic net loss per share of common stock for those periods.

Segment Reporting

Segment Reporting

Operating segments are defined as components of an entity for which separate financial information is available and that is regularly reviewed by the Chief Operating Decision Maker (CODM) in deciding how to allocate resources to an individual segment and in assessing performance. The Company’s CODM is its Chief Executive Officer. The Company has determined it operates in one segment, the development and commercialization of innovative and minimally invasive products to treat bladder and bowel dysfunction. Geographically, the Company sells over 90% of its products to customers in the United States. Segment information is consistent with how management reviews the business, makes investing and resource allocation decisions and assesses operating performance.

Recent Accounting Pronouncements

Recent Accounting Pronouncements

We have reviewed and considered all recent accounting pronouncements that have not yet been adopted and believe there are none that could potentially have a material impact on our business practices, financial condition, results of operations, or disclosures.

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Nature of Operations and Summary of Significant Accounting Policies (Tables)

6 Months Ended

Jun. 30, 2023

Organization, Consolidation and Presentation of Financial Statements [Abstract]

Schedule of Revenue Disaggregated by Product and Geographic Market

The following table provides additional information pertaining to net revenue disaggregated by product and geographic market for the three and six months ended June 30, 2023 and 2022 (in thousands):

	Three Months Ended June 30,				Six Months Ended June 30,
	2023		2022		2023		2022
SNM net revenue
United States	$	72,205	$	54,468	$	126,058	$	92,183
International markets	1,983		1,290		3,288		2,645
	$	74,188	$	55,758	$	129,346	$	94,828
Bulkamid net revenue
United States	$	14,806	$	10,223	$	26,419	$	16,792
International markets	3,900		2,999		7,779		5,780
	$	18,706	$	13,222	$	34,198	$	22,572
Total net revenue	$	92,894	$	68,980	$	163,544	$	117,400

Schedule of Changes in Allowance for Credit Losses

The following table summarizes the changes in our allowance for credit losses (in thousands):

	Six Months Ended June 30,
	2023		2022
Balance at beginning of period	$	321	$	355
Write-offs	—		—
Bad debt expense (recoveries)	46		(50)
Balance at end of period	$	367	$	305

Schedule of Changes in Fair Value of Liabilities Measured on Recurring Basis

The following table summarizes the changes in the fair value of recurring Level 3 fair value measurements during the six months ended June 30, 2023 and 2022 (in thousands):

	Six Months Ended June 30,
	2023		2022
Liabilities
Contingent consideration:
Balance at beginning of period	$	32,600	$	10,370
Change in fair value included in earnings	2,400		12,030
Payment made	(35,000)		—
Balance at end of period	$	—	$	22,400

Schedule of Fair Value Hierarchy for Assets Measured on Recurring Basis

The following table presents the fair value hierarchy for those assets measured at fair value on a recurring basis as of June 30, 2023 and December 31, 2022 (in thousands):

	Fair Value Measurements at June 30, 2023
Assets:	Level 1		Level 2		Level 3		Total
Commercial paper	$	—	$	119,763	$	—	$	119,763
Corporate notes	—		5,700		—		5,700
U.S. government and agency securities	171,760		—		—		171,760
	$	171,760	$	125,463	$	—	$	297,223

_____________________________________________

(1)    As of June 30, 2023, commercial paper investments of $81.1 million and U.S. government and agency securities of $30.0 million are included in cash and cash equivalents on the unaudited condensed consolidated balance sheets, as the investments had a maturity of three months or less from the date of purchase.

	Fair Value Measurements at December 31, 2022
Assets:	Level 1		Level 2		Level 3		Total
Commercial paper	$	—	$	175,548	$	—	$	175,548
Corporate notes	—		4,675		—		4,675
U.S. government and agency securities	75,212		—		—		75,212
	$	75,212	$	180,223	$	—	$	255,435

_____________________________________________

(1)    As of December 31, 2022, commercial paper investments of $131.1 million, U.S. government and agency securities of $4.0 million, and corporate notes of $2.0 million are included in cash and cash equivalents on the unaudited condensed consolidated balance sheets, as the investments had a maturity of three months or less from the date of purchase.

Schedule of Available-for-sale Debt Securities By Significant Investment Category

The following table summarizes the Company’s cash equivalents and investments in available-for-sale debt securities by significant investment category as of June 30, 2023 and December 31, 2022 (in thousands):

	June 30, 2023
	Cost		Unrealized gains		Unrealized losses		Fair value
Cash equivalents:
Commercial paper	$	81,063	$	—	$	—	$	81,063
Corporate notes	—		—		—		—
U.S. government and agency securities	29,987		—		—		29,987
Total cash equivalents	$	111,050	$	—	$	—	$	111,050
Short-term investments:
Commercial paper	$	38,700	$	—	$	—	$	38,700
Corporate notes	5,709		—		(9)		5,700
U.S. government and agency securities	141,805		3		(35)		141,773
Total short-term investments	$	186,214	$	3	$	(44)	$	186,173
Total	$	297,264	$	3	$	(44)	$	297,223

	December 31, 2022
	Cost		Unrealized gains		Unrealized losses		Fair value
Cash equivalents:
Commercial paper	$	131,075	$	—	$	—	$	131,075
Corporate notes	2,013		—		—		2,013
U.S. government and agency securities	3,982		—		—		3,982
Total cash equivalents	$	137,070	$	—	$	—	$	137,070
Short-term investments:
Commercial paper	$	44,473	$	—	$	—	$	44,473
Corporate notes	2,664		—		(2)		2,662
U.S. government and agency securities	71,342		6		(118)		71,230
Total short-term investments	$	118,479	$	6	$	(120)	$	118,365
Total	$	255,549	$	6	$	(120)	$	255,435

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Property and Equipment, Net (Tables)

6 Months Ended

Jun. 30, 2023

Property, Plant and Equipment [Abstract]

Schedule of Property and Equipment, Net

Property and equipment, net consists of the following (in thousands) at:

	June 30,		December 31,
	2023		2022
Equipment	$	2,782	$	2,645
Computer hardware and software	3,295		3,282
Tools and molds	2,225		1,735
Leasehold improvements	4,449		4,449
Furniture and fixtures	1,874		1,810
Construction in progress	794		413
	15,419		14,334
Less: accumulated depreciation and amortization	(9,070)		(7,536)
	$	6,349	$	6,798

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Commitments and Contingencies (Tables)

6 Months Ended

Jun. 30, 2023

Commitments and Contingencies Disclosure [Abstract]

Schedule of Total Lease Cost

Total lease costs for the three and six months ended June 30, 2023 and 2022 are as follows (in thousands):

	Three Months Ended June 30,				Six Months Ended June 30,
	2023		2022		2023		2022
Lease cost
Operating lease cost	$	546	$	524	$	1,088	$	1,048
Short-term lease cost	22		20		45		41
Variable lease cost	178		132		285		257
Amortization of net lease liabilities	(656)		(94)		(723)		(184)
Total lease cost	$	90	$	582	$	695	$	1,162

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Stock-Based Compensation (Tables)

6 Months Ended

Jun. 30, 2023

Equity [Abstract]

Schedule of Stock-based Compensation Expense

Stock-based compensation expense included in the Company’s unaudited condensed consolidated statements of comprehensive loss is allocated as follows (in thousands):

	Three Months Ended June 30,				Six Months Ended June 30,
	2023		2022		2023		2022
Research and development	$	2,414	$	1,752	$	4,618	$	3,262
General and administrative	3,059		1,991		5,885		3,928
Sales and marketing	5,731		4,162		11,415		7,853
	$	11,204	$	7,905	$	21,918	$	15,043

Schedule of Stock Option Activity

The following table summarizes stock option activity for the six months ended June 30, 2023 under the 2014 and 2018 Plans (in thousands, except share and per share data):

	Number of Options	Weighted-Average Exercise Price Per Share		Aggregate Intrinsic Value
Outstanding at December 31, 2022	1,046,610	$	18.81
Options exercised	(159,681)	17.50		$	6,978	(1)
Options forfeited	(585)	29.71
Outstanding at June 30, 2023	886,344	$	19.03	$	28,118	(2)

_____________________________________________

(1)    Represents the total difference between the Company’s closing stock price at the time of exercise and the stock option exercise price, multiplied by the number of options exercised.

(2)    Represents the total difference between the Company’s closing stock price on the last trading day of the second quarter of 2023 and the stock option exercise price, multiplied by the number of in-the-money options as of June 30, 2023. The amount of intrinsic value will change based on the fair market value of the Company’s stock.

Schedule of Restricted Shares Awards and Restricted Stock Units Activity

The following table summarizes restricted shares awards activity for the six months ended June 30, 2023:

	Number of Restricted Shares Awards	Weighted-Average Fair Value Per Share at Grant Date
Outstanding at December 31, 2022	1,320,866	$	52.23
Restricted shares awards granted	349,866	57.11
Restricted shares awards vested	(342,907)	43.28
Restricted shares awards forfeited	(59,518)	55.23
Outstanding at June 30, 2023	1,268,307	$	55.86

The following table summarizes restricted stock units activity for the six months ended June 30, 2023:

	Number of Restricted Stock Units	Weighted-Average Fair Value Per Share at Grant Date
Outstanding at December 31, 2022	183,418	$	48.74
Restricted stock units granted	286,750	65.44
Restricted stock units vested	(199,718)	49.84
Outstanding at June 30, 2023	270,450	$	70.10

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Income Taxes (Tables)

6 Months Ended

Jun. 30, 2023

Income Tax Disclosure [Abstract]

Schedule of Provision for Income Taxes and Effective Tax Rates

The following table presents details of the provision for income taxes and effective tax rates (in thousands, except percentages):

	Three Months Ended June 30,		Six Months Ended June 30,
	2023	2022	2023	2022
Income tax benefit	$(304)	$(465)	$(1,111)	$(1,576)
Effective tax rate	3.97%	2.13%	6.27%	3.45%

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Goodwill and Intangible Assets (Tables)

6 Months Ended

Jun. 30, 2023

Goodwill and Intangible Assets Disclosure [Abstract]

Schedule of Carrying Amount of Goodwill

The change in the carrying amount of goodwill during the six months ended June 30, 2023 included the following (in thousands):

December 31, 2022	$	94,414
Foreign currency translation adjustment	4,466
June 30, 2023	$	98,880

Schedule of Indefinite-Lived Intangible Assets

Intangible assets as of June 30, 2023 included the following (in thousands):

		June 30, 2023
	Weighted-Average Amortization Period	Gross Carrying Amount		Accumulated Amortization		Impairment		Foreign currency translation adjustment		Intangible Assets, Net
Patent license asset	8.71 years	$	1,000	$	(1,000)	$	—	$	—	$	—
Exclusive license asset	4 years	3,300		(1,980)		—		—		1,320
Technology	12 years	81,100		(15,863)		—		(6,380)		58,857
Trade names and trademarks	Indefinite	19,700		—		—		(1,580)		18,120
Customer relationships	12 years	11,400		(3,087)		(287)		(780)		7,246
		$	116,500	$	(21,930)	$	(287)	$	(8,740)	$	85,543

Intangible assets as of December 31, 2022 included the following (in thousands):

		December 31, 2022
	Weighted-Average Amortization Period	Gross Carrying Amount		Accumulated Amortization		Impairment		Foreign currency translation adjustment		Intangible Asset, Net
Patent license asset	8.71 years	$	1,000	$	(1,000)	$	—	$	—	$	—
Exclusive license asset	4 years	3,300		(1,540)		—		—		1,760
Technology	12 years	81,100		(12,496)		—		(9,141)		59,463
Trade names and trademarks	Indefinite	19,700		—		—		(2,398)		17,302
Customer relationships	12 years	11,400		(2,393)		(287)		(992)		7,728
		$	116,500	$	(17,429)	$	(287)	$	(12,531)	$	86,253

Schedule of Finite-Lived Intangible Assets

Intangible assets as of June 30, 2023 included the following (in thousands):

		June 30, 2023
	Weighted-Average Amortization Period	Gross Carrying Amount		Accumulated Amortization		Impairment		Foreign currency translation adjustment		Intangible Assets, Net
Patent license asset	8.71 years	$	1,000	$	(1,000)	$	—	$	—	$	—
Exclusive license asset	4 years	3,300		(1,980)		—		—		1,320
Technology	12 years	81,100		(15,863)		—		(6,380)		58,857
Trade names and trademarks	Indefinite	19,700		—		—		(1,580)		18,120
Customer relationships	12 years	11,400		(3,087)		(287)		(780)		7,246
		$	116,500	$	(21,930)	$	(287)	$	(8,740)	$	85,543

Intangible assets as of December 31, 2022 included the following (in thousands):

		December 31, 2022
	Weighted-Average Amortization Period	Gross Carrying Amount		Accumulated Amortization		Impairment		Foreign currency translation adjustment		Intangible Asset, Net
Patent license asset	8.71 years	$	1,000	$	(1,000)	$	—	$	—	$	—
Exclusive license asset	4 years	3,300		(1,540)		—		—		1,760
Technology	12 years	81,100		(12,496)		—		(9,141)		59,463
Trade names and trademarks	Indefinite	19,700		—		—		(2,398)		17,302
Customer relationships	12 years	11,400		(2,393)		(287)		(992)		7,728
		$	116,500	$	(17,429)	$	(287)	$	(12,531)	$	86,253

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Nature of Operations and Summary of Significant Accounting Policies - Narrative (Details)				1 Months Ended	3 Months Ended				6 Months Ended		12 Months Ended
	Aug. 05, 2022 USD ($) $ / shares shares	Mar. 02, 2021 USD ($) shares	Feb. 25, 2021 USD ($) shares	Apr. 30, 2023 USD ($) $ / shares shares	Jun. 30, 2023 USD ($) shares	Mar. 31, 2023 USD ($)	Jun. 30, 2022 USD ($) shares	Mar. 31, 2022 USD ($)	Jun. 30, 2023 USD ($) segment shares	Jun. 30, 2022 USD ($) shares	Dec. 31, 2022 USD ($)	Dec. 31, 2013 USD ($) shares
Basis of Presentation and Liquidity
Net loss					$ 7,342,000	$ 9,248,000	$ 21,443,000	$ 22,668,000	$ 16,590,000	$ 44,111,000
Accumulated deficit					390,854,000				390,854,000		$ 374,264,000
Cash, cash equivalents, and short-term investments					331,500,000				331,500,000		357,200,000
Outstanding borrowings					0				0
Revenue Recognition
Allowance for product returns					200,000				200,000		200,000
Replacement costs					0		0		100,000	100,000
Warranty liability					100,000				100,000		100,000
Investment Securities:
Unrealized gain (loss) on investment securities					0		0		0	0
Inventory:
Finished goods inventory					37,900,000				37,900,000		30,400,000
Work-in-process inventory					9,500,000				9,500,000		5,700,000
Raw materials inventory					22,700,000				22,700,000		19,700,000
Inventory reserves					900,000				900,000		500,000
Goodwill:
Impairment charges related to goodwill									0	0
Intangible Asset:
Amortization of intangible assets					2,279,000		2,332,000		4,501,000	4,795,000
Impairment of Long-Lived Assets:
Impairment of long-lived assets									300,000
Impairment of indefinite-lived intangible assets									0
Advertising Expense:
Advertising expense					$ 4,100,000		$ 6,300,000		$ 8,400,000	$ 9,500,000
Net Loss per Share of Common Stock:
Potentially dilutive weighted-average shares not included in computation of diluted weighted average shares (in shares) | shares					2,124,449		2,403,317		2,144,301	2,414,973
Segment Reporting
Number of operating segments | segment									1
Radian, LLC
Acquisition of in-process research & development from Radian, LLC
Consideration amount, equity interest issued and issuable (in shares) | shares				264,783
Consideration amount, contingent consideration				$ 2,500,000
Acquired in-process research and development				$ 15,400,000
Consideration amount, per share (in USD per share) | $ / shares				$ 58.34
Revenue Benchmark | Geographic Concentration Risk | United States
Segment Reporting
Concentration risk, percentage									90.00%
Restricted Stock Units
Stock-Based Compensation:
Vesting period									1 year
Patent license asset
Intangible Asset:
Finite-lived intangible asset acquired												$ 1,000,000
Finite-lived intangible assets, weighted-average amortization period												8 years 8 months 15 days
Exclusive license asset
Intangible Asset:
Finite-lived intangible asset acquired		$ 3,300,000
Finite-lived intangible assets, weighted-average amortization period		4 years
Vendor credit in accounts payable		$ 300,000
Amortization of intangible assets					$ 200,000		$ 200,000		$ 400,000	$ 400,000
Impairment of intangible asset									$ 0
Preferred Stock | Patent license asset
Intangible Asset:
Stock issued for purchase of intangible asset (in shares) | shares												50,000
Fair value of shares issued for purchase of intangible asset												$ 1,000,000
Common Stock | Exclusive license asset
Intangible Asset:
Stock issued for purchase of intangible asset (in shares) | shares		65,594
Fair value of shares issued for purchase of intangible asset		$ 3,600,000
Minimum
Inventory:
Inventory shelf life									12 months
Property and Equipment:
Property and equipment useful life					3 years				3 years
Stock-Based Compensation:
Requisite service period of recognition of compensation cost									3 years
Minimum | Stock Option and Restricted Stock-Based Awards
Stock-Based Compensation:
Vesting period									3 years
Maximum
Inventory:
Inventory shelf life									36 months
Property and Equipment:
Property and equipment useful life					7 years				7 years
Stock-Based Compensation:
Requisite service period of recognition of compensation cost									4 years
Maximum | Stock Option and Restricted Stock-Based Awards
Stock-Based Compensation:
Vesting period									4 years
Contura
Fair Value of Financial Instruments
Cash consideration transferred			$ 141,300,000
Stock transferred in acquisition (in shares) | shares			1,096,583
Maximum contingent consideration			$ 35,000,000
Contingent consideration, term			12 months
Amount of sales to achieve for maximum contingent consideration			$ 50,000,000
Contingent consideration, milestone met payment term after quarter			50 days
Intangible Asset:
Amortization of intangible assets					$ 2,000,000		$ 2,100,000		$ 4,100,000	$ 4,300,000
Contura | Customer relationships
Intangible Asset:
Impairment of intangible asset											300,000
Contura | Contingent Consideration Liability
Fair Value of Financial Instruments
Contingent consideration at fair value											$ 32,600,000
Follow-on Offering
August 2022 Follow-On Offering
Stock issued (in shares) | shares	2,012,500
Sale of stock, price per share (in USD per share) | $ / shares	$ 63.85
Net proceeds from sale of stock	$ 128,300,000
Exercise of Underwriters Option
August 2022 Follow-On Offering
Stock issued (in shares) | shares	262,500

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Nature of Operations and Summary of Significant Accounting Policies - Schedule of Revenue Disaggregated by Geographic Market (Details) - USD ($) $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2023	Jun. 30, 2022	Jun. 30, 2023	Jun. 30, 2022
Disaggregation of Revenue [Line Items]
Net revenue	$ 92,894	$ 68,980	$ 163,544	$ 117,400
SNM net revenue
Disaggregation of Revenue [Line Items]
Net revenue	74,188	55,758	129,346	94,828
Bulkamid net revenue
Disaggregation of Revenue [Line Items]
Net revenue	18,706	13,222	34,198	22,572
United States | SNM net revenue
Disaggregation of Revenue [Line Items]
Net revenue	72,205	54,468	126,058	92,183
United States | Bulkamid net revenue
Disaggregation of Revenue [Line Items]
Net revenue	14,806	10,223	26,419	16,792
International markets | SNM net revenue
Disaggregation of Revenue [Line Items]
Net revenue	1,983	1,290	3,288	2,645
International markets | Bulkamid net revenue
Disaggregation of Revenue [Line Items]
Net revenue	$ 3,900	$ 2,999	$ 7,779	$ 5,780

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Nature of Operations and Summary of Significant Accounting Policies - Schedule of Changes in Allowance for Doubtful Accounts (Details) - USD ($) $ in Thousands	6 Months Ended
	Jun. 30, 2023	Jun. 30, 2022
Accounts Receivable, Allowance for Credit Loss [Roll Forward]
Balance at beginning of period	$ 321	$ 355
Write-offs	0	0
Bad debt expense (recoveries)	46	(50)
Balance at end of period	$ 367	$ 305

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Nature of Operations and Summary of Significant Accounting Policies - Schedule of Changes in Fair Value of Liabilities Measured on Recurring Basis (Details) - USD ($) $ in Thousands	6 Months Ended
	Jun. 30, 2023	Jun. 30, 2022
Contingent consideration:
Change in fair value included in earnings	$ 2,400	$ 12,030
Level 3 | Contingent Consideration Liability | Fair Value, Recurring
Contingent consideration:
Balance at beginning of period	32,600	10,370
Change in fair value included in earnings	2,400	12,030
Payment made	(35,000)	0
Balance at end of period	$ 0	$ 22,400

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Nature of Operations and Summary of Significant Accounting Policies - Schedule of Fair Value Hierarchy for Assets Measured on Recurring Basis (Details) - USD ($) $ in Thousands	Jun. 30, 2023	Dec. 31, 2022
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Fair value	$ 186,173	$ 118,365
Commercial paper included in cash and cash equivalents	81,100	131,100
U.S. government and agency securities included in cash and cash equivalents	30,000	4,000
Corporate notes included in cash and cash equivalents		2,000
Commercial paper
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Fair value	38,700	44,473
Corporate notes
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Fair value	5,700	2,662
U.S. government and agency securities
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Fair value	141,773	71,230
Fair Value, Recurring
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Fair value	297,223	255,435
Fair Value, Recurring | Commercial paper
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Fair value	119,763	175,548
Fair Value, Recurring | Corporate notes
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Fair value	5,700	4,675
Fair Value, Recurring | U.S. government and agency securities
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Fair value	171,760	75,212
Fair Value, Recurring | Level 1
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Fair value	171,760	75,212
Fair Value, Recurring | Level 1 | Commercial paper
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Fair value	0	0
Fair Value, Recurring | Level 1 | Corporate notes
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Fair value	0	0
Fair Value, Recurring | Level 1 | U.S. government and agency securities
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Fair value	171,760	75,212
Fair Value, Recurring | Level 2
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Fair value	125,463	180,223
Fair Value, Recurring | Level 2 | Commercial paper
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Fair value	119,763	175,548
Fair Value, Recurring | Level 2 | Corporate notes
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Fair value	5,700	4,675
Fair Value, Recurring | Level 2 | U.S. government and agency securities
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Fair value	0	0
Fair Value, Recurring | Level 3
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Fair value	0	0
Fair Value, Recurring | Level 3 | Commercial paper
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Fair value	0	0
Fair Value, Recurring | Level 3 | Corporate notes
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Fair value	0	0
Fair Value, Recurring | Level 3 | U.S. government and agency securities
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Fair value	$ 0	$ 0

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Nature of Operations and Summary of Significant Accounting Policies - Schedule of Available-for-sale Debt Securities By Significant Investment Category (Details) - USD ($) $ in Thousands	Jun. 30, 2023	Dec. 31, 2022
Debt Securities, Available-for-Sale [Line Items]
Cost	$ 111,050	$ 137,070
Fair value	111,050	137,070
Cost	186,214	118,479
Unrealized gains	3	6
Unrealized losses	(44)	(120)
Fair value	186,173	118,365
Cash and cash equivalents and short term investments, amortized cost	297,264	255,549
Cash and cash equivalents and short term investments, fair value	297,223	255,435
Commercial paper
Debt Securities, Available-for-Sale [Line Items]
Cost	81,063	131,075
Fair value	81,063	131,075
Cost	38,700	44,473
Unrealized gains	0	0
Unrealized losses	0	0
Fair value	38,700	44,473
Corporate notes
Debt Securities, Available-for-Sale [Line Items]
Cost	0	2,013
Fair value	0	2,013
Cost	5,709	2,664
Unrealized gains	0	0
Unrealized losses	(9)	(2)
Fair value	5,700	2,662
U.S. government and agency securities
Debt Securities, Available-for-Sale [Line Items]
Cost	29,987	3,982
Fair value	29,987	3,982
Cost	141,805	71,342
Unrealized gains	3	6
Unrealized losses	(35)	(118)
Fair value	$ 141,773	$ 71,230

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Property and Equipment, Net - Schedule of Property and Equipment, Net (Details) - USD ($) $ in Thousands	Jun. 30, 2023	Dec. 31, 2022
Property, Plant and Equipment [Line Items]
Property and equipment, gross	$ 15,419	$ 14,334
Less: accumulated depreciation and amortization	(9,070)	(7,536)
Property and equipment, net	6,349	6,798
Equipment
Property, Plant and Equipment [Line Items]
Property and equipment, gross	2,782	2,645
Computer hardware and software
Property, Plant and Equipment [Line Items]
Property and equipment, gross	3,295	3,282
Tools and molds
Property, Plant and Equipment [Line Items]
Property and equipment, gross	2,225	1,735
Leasehold improvements
Property, Plant and Equipment [Line Items]
Property and equipment, gross	4,449	4,449
Furniture and fixtures
Property, Plant and Equipment [Line Items]
Property and equipment, gross	1,874	1,810
Construction in progress
Property, Plant and Equipment [Line Items]
Property and equipment, gross	$ 794	$ 413

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Property and Equipment, Net - Narrative (Details) - USD ($) $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2023	Jun. 30, 2022	Jun. 30, 2023	Jun. 30, 2022
Property, Plant and Equipment [Line Items]
Depreciation and amortization expense			$ 6,041	$ 5,920
Property and Equipment
Property, Plant and Equipment [Line Items]
Depreciation and amortization expense	$ 900	$ 500	$ 1,500	$ 1,100

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Commitments and Contingencies - Narrative (Details)	3 Months Ended		6 Months Ended
	Jun. 30, 2023 USD ($)	Jun. 30, 2022 USD ($)	Jun. 30, 2023 USD ($)	Jun. 30, 2022 USD ($)	Apr. 30, 2023 ft²	Dec. 31, 2022 USD ($)	Mar. 31, 2022 ft²	Aug. 31, 2020 ft²	Jun. 30, 2019 ft²	Aug. 01, 2018 ft²	Aug. 31, 2014 ft²
Loss Contingencies [Line Items]
Right-of-use assets obtained in exchange for operating lease liabilities	$ 0	$ 0	$ 0	$ 0
Right-of-use assets	700,000		700,000			$ 6,200,000
Cash paid for operating lease liabilities	500,000	500,000	1,000,000	1,000,000
Amortization of the ROU assets	$ 100,000	300,000	$ 400,000	500,000
Weighted-average remaining lease terms for operating leases	1 year 2 months 12 days		1 year 2 months 12 days			4 years 10 months 24 days
Weighted-average incremental borrowing rate for a collateralized asset of the same remaining term (as a percent)	5.90%		5.90%			7.10%
Period after first sale royalty is due			12 years
Net revenue due as royalty (as a percent)			4.00%
Royalty expense	$ 800,000	$ 600,000	$ 1,100,000	$ 2,200,000
Accrued royalty expense	$ 700,000		$ 700,000			$ 600,000
Royalty payment percentage	4.00%		4.00%
Maximum
Loss Contingencies [Line Items]
Royalty commitments	$ 200,000		$ 200,000
First Lease
Loss Contingencies [Line Items]
Term of operating lease contract											5 years
Net rentable area (square feet) | ft²											12,215
Second Lease
Loss Contingencies [Line Items]
Net rentable area (square feet) | ft²										25,548
Renewal term of operating lease										5 years
Third Lease
Loss Contingencies [Line Items]
Term of operating lease contract									8 years
Net rentable area (square feet) | ft²									32,621
Renewal term of operating lease									5 years
Fourth Lease
Loss Contingencies [Line Items]
Term of operating lease contract								38 months
Net rentable area (square feet) | ft²								5,693
Fifth Lease
Loss Contingencies [Line Items]
Term of operating lease contract							18 months
Net rentable area (square feet) | ft²							3,276
Sixth Lease
Loss Contingencies [Line Items]
Term of operating lease contract					120 months
Net rentable area (square feet) | ft²					145,960
Renewal term of operating lease					5 years

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Commitments and Contingencies - Schedule of Total Lease Cost (Details) - USD ($) $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2023	Jun. 30, 2022	Jun. 30, 2023	Jun. 30, 2022
Commitments and Contingencies Disclosure [Abstract]
Operating lease cost	$ 546	$ 524	$ 1,088	$ 1,048
Short-term lease cost	22	20	45	41
Variable lease cost	178	132	285	257
Amortization of net lease liabilities	(656)	(94)	(723)	(184)
Total lease cost	$ 90	$ 582	$ 695	$ 1,162

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Stock-Based Compensation - Schedule of Stock-based Compensation Expense (Details) - USD ($) $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2023	Jun. 30, 2022	Jun. 30, 2023	Jun. 30, 2022
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Share-based compensation expense	$ 11,204	$ 7,905	$ 21,918	$ 15,043
Research and development
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Share-based compensation expense	2,414	1,752	4,618	3,262
General and administrative
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Share-based compensation expense	3,059	1,991	5,885	3,928
Sales and marketing
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Share-based compensation expense	$ 5,731	$ 4,162	$ 11,415	$ 7,853

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Stock-Based Compensation - Narrative (Details) - USD ($) $ in Millions	3 Months Ended		6 Months Ended		12 Months Ended
	Jun. 30, 2023	Jun. 30, 2022	Jun. 30, 2023	Jun. 30, 2022	Dec. 31, 2022
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Options granted (in shares)	0	0	0	0
Stock Options
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Unrecognized compensation cost related to unvested stock options	$ 0.7		$ 0.7		$ 1.8
Weighted-average period of recognition of compensation cost			9 months 18 days		1 year
Weighted-average remaining contractual term of options outstanding and exercisable			5 years 8 months 12 days		6 years 1 month 6 days
Restricted Shares Awards
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Weighted-average period of recognition of compensation cost			2 years 1 month 6 days		2 years 3 months 18 days
Unrecognized compensation cost related to unvested RSAs or RSUs	56.8		$ 56.8		$ 54.0
Restricted Stock Units
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Weighted-average period of recognition of compensation cost			1 year		9 months 18 days
Unrecognized compensation cost related to unvested RSAs or RSUs	$ 11.4		$ 11.4		$ 1.3

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Stock-Based Compensation - Schedule of Stock Option Activity (Details) $ / shares in Units, $ in Thousands	6 Months Ended
	Jun. 30, 2023 USD ($) $ / shares shares
Number of Options
Outstanding at beginning of period (in shares) | shares	1,046,610
Options exercised (in shares) | shares	(159,681)
Options forfeited (in shares) | shares	(585)
Outstanding at end of period (in shares) | shares	886,344
Weighted-Average Exercise Price Per Share
Outstanding at beginning of period (in USD per share) | $ / shares	$ 18.81
Options exercised (in USD per share) | $ / shares	17.50
Options forfeited (in USD per share) | $ / shares	29.71
Outstanding at end of period (in USD per share) | $ / shares	$ 19.03
Aggregate Intrinsic Value
Intrinsic value of options exercised | $	$ 6,978
Intrinsic value of options outstanding | $	$ 28,118

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Stock-Based Compensation - Schedule of Restricted Shares Awards Activity (Details) - Restricted Shares Awards	6 Months Ended
	Jun. 30, 2023 $ / shares shares
Number of Restricted Shares Awards
Outstanding at beginning of period (in shares) | shares	1,320,866
Restricted shares granted (in shares) | shares	349,866
Restricted shares vested (in shares) | shares	(342,907)
Restricted shares forfeited (in shares) | shares	(59,518)
Outstanding at end of period (in shares) | shares	1,268,307
Weighted-Average Fair Value Per Share at Grant Date
Outstanding at beginning of period (in USD per share) | $ / shares	$ 52.23
Restricted shares granted (in USD per share) | $ / shares	57.11
Restricted shares vested (in USD per share) | $ / shares	43.28
Restricted shares forfeited (in USD per share) | $ / shares	55.23
Outstanding at end of period (in USD per share) | $ / shares	$ 55.86

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Stock-Based Compensation - Schedule of Restricted Stock Units Activity (Details) - Restricted Stock Units	6 Months Ended
	Jun. 30, 2023 $ / shares shares
Number of Restricted Stock Units
Outstanding at beginning of period (in shares) | shares	183,418
Restricted shares granted (in shares) | shares	286,750
Restricted shares vested (in shares) | shares	(199,718)
Outstanding at end of period (in shares) | shares	270,450
Weighted-Average Fair Value Per Share at Grant Date
Outstanding at beginning of period (in USD per share) | $ / shares	$ 48.74
Restricted shares granted (in USD per share) | $ / shares	65.44
Restricted shares vested (in USD per share) | $ / shares	49.84
Outstanding at end of period (in USD per share) | $ / shares	$ 70.10

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Income Taxes - Schedule of Provision for Income Taxes and Effective Tax Rates (Details) - USD ($) $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2023	Jun. 30, 2022	Jun. 30, 2023	Jun. 30, 2022
Income Tax Disclosure [Abstract]
Income tax benefit	$ (304)	$ (465)	$ (1,111)	$ (1,576)
Effective tax rate	3.97%	2.13%	6.27%	3.45%

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Income Taxes - Narrative (Details) $ in Millions	Dec. 31, 2022 USD ($)
Domestic Tax Authority
Operating Loss Carryforwards [Line Items]
Operating loss carryforwards	$ 270.3
Operating loss carryforwards, subject to expiration	51.5
Foreign Tax Authority
Operating Loss Carryforwards [Line Items]
Operating loss carryforwards	9.6
State and Local Jurisdiction
Operating Loss Carryforwards [Line Items]
Operating loss carryforwards, subject to expiration	$ 254.6

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Employee Benefit Plan (Details) - USD ($) $ in Millions	3 Months Ended		6 Months Ended
	Jun. 30, 2023	Jun. 30, 2022	Jun. 30, 2023	Jun. 30, 2022
Retirement Benefits [Abstract]
Contributions by employer	$ 0.6	$ 0.5	$ 1.2	$ 1.0

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Goodwill and Intangible Assets - Schedule of Carrying Amount of Goodwill (Details) $ in Thousands	6 Months Ended
	Jun. 30, 2023 USD ($)
Goodwill [Roll Forward]
Balance at beginning of period	$ 94,414
Foreign currency translation adjustment	4,466
Balance at end of period	$ 98,880

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Goodwill and Intangible Assets - Schedule of Finite-Lived and Indefinite-Lived Intangible Assets (Details) - USD ($) $ in Thousands	Jun. 30, 2023	Dec. 31, 2022
Finite-Lived Intangible Assets, Net:
Accumulated Amortization	$ (21,930)	$ (17,429)
Impairment	(287)	(287)
Intangible Assets, Net (Excluding Goodwill):
Gross Carrying Amount	116,500	116,500
Accumulated Amortization	(21,930)	(17,429)
Foreign currency translation adjustment	(8,740)	(12,531)
Intangible assets, net	85,543	86,253
Trade names and trademarks
Indefinite-lived Intangible Assets:
Gross Carrying Amount	19,700	19,700
Foreign currency translation adjustment	(1,580)	(2,398)
Intangible Assets, Net	$ 18,120	$ 17,302
Patent license asset
Finite-Lived Intangible Assets [Line Items]
Weighted-Average Amortization Period	8 years 8 months 15 days	8 years 8 months 15 days
Finite-Lived Intangible Assets, Net:
Gross Carrying Amount	$ 1,000	$ 1,000
Accumulated Amortization	(1,000)	(1,000)
Impairment	0	0
Foreign currency translation adjustment	0	0
Intangible Assets, Net	0	0
Intangible Assets, Net (Excluding Goodwill):
Accumulated Amortization	$ (1,000)	$ (1,000)
Exclusive license asset
Finite-Lived Intangible Assets [Line Items]
Weighted-Average Amortization Period	4 years	4 years
Finite-Lived Intangible Assets, Net:
Gross Carrying Amount	$ 3,300	$ 3,300
Accumulated Amortization	(1,980)	(1,540)
Impairment	0	0
Foreign currency translation adjustment	0	0
Intangible Assets, Net	1,320	1,760
Intangible Assets, Net (Excluding Goodwill):
Accumulated Amortization	$ (1,980)	$ (1,540)
Technology
Finite-Lived Intangible Assets [Line Items]
Weighted-Average Amortization Period	12 years	12 years
Finite-Lived Intangible Assets, Net:
Gross Carrying Amount	$ 81,100	$ 81,100
Accumulated Amortization	(15,863)	(12,496)
Impairment	0	0
Foreign currency translation adjustment	(6,380)	(9,141)
Intangible Assets, Net	58,857	59,463
Intangible Assets, Net (Excluding Goodwill):
Accumulated Amortization	$ (15,863)	$ (12,496)
Customer relationships
Finite-Lived Intangible Assets [Line Items]
Weighted-Average Amortization Period	12 years	12 years
Finite-Lived Intangible Assets, Net:
Gross Carrying Amount	$ 11,400	$ 11,400
Accumulated Amortization	(3,087)	(2,393)
Impairment	(287)	(287)
Foreign currency translation adjustment	(780)	(992)
Intangible Assets, Net	7,246	7,728
Intangible Assets, Net (Excluding Goodwill):
Accumulated Amortization	$ (3,087)	$ (2,393)