SUMMARY
Infertility diagnoses among veterans have been increasing over the years, particularly among those that have deployed in support of Operation Iraqi Freedom (OIF) in Iraq and Operation Enduring Freedom (OEF) in Afghanistan (Katon, et al., 2014). Policymakers have proposed bills that include variations of coverage, from in vitro fertilization (IVF) to surrogacy and adoption, for service members who have a service-connected reproductive disorder. These reproductive disabilities aren’t always diagnosed, however, and even when they are it can be difficult to prove whether or not they are service-connected.
The American Society for Reproductive Medicine (ASRM) defines infertility as a disease (ASRM, 2013). It is not a quality of life issue, but an actual reproductive disorder that requires medical treatment in order to be resolved. Our veterans have a right to receive treatment for any disability incurred in the line of duty, and reproductive disorders should not be an exception. In order to properly diagnose and treat these issues, research needs to be conducted to determine the correlation between infertility and the multiple factors to which the service members are exposed during their deployments.
This brief aims to outline possible reasons for under-diagnoses of infertility and identify possible deployment-related causes, and provide recommendations to policymakers and Department of Veterans Affairs (VA) representatives in order to make the best use of bills that are currently being debated regarding veteran’s fertility treatments.
CONTEXT
Multiple studies have shown an increase in the number of both male and female service members who have trouble conceiving after military deployments. However, there is a discrepancy between self-reported infertility diagnoses and those reported in the Defense Manpower Data Center (DMDC) which tracks the health care of veterans who have utilized VA health services after separating from the military (Katon et al., 2014; Mattocks et al., 2015). According to a study conducted by Katon et al., 15.8% of women veterans and 13.8 % of male veterans who served in OIF or OEF between October 2001 and June 2008 reported having received an infertility diagnosis (Katon et al. 2014). Because this study depended on self-reporting among the veterans, it accounts not only for diagnoses received by Tricare or the VA, but also for diagnoses received from civilian doctors that were not recorded in their military or veteran records. On the other hand, a study conducted by Mattocks et al. on infertility care among women veterans discharged between October 2001 and December 2010 indicated that only 1.9 % of women veterans received infertility diagnoses during that period (Mattocks et al., 2015).
This discrepancy, coupled with statistical data that indicates approximately one in eight couples in the US have trouble achieving or maintaining a pregnancy (Chandra, Copen, & Steven, 2013), points to the likelihood that the VA is significantly underestimating the number of infertile veterans. The reason for the discrepancy is unclear, however it may be due to the way the VA prioritizes physical ailments, and they may pay less attention to reproductive disorders that don’t necessarily affect daily function. There is no data to indicate the percentage of veterans with service-connected infertility, but I would imagine it is extremely low considering less than two percent have infertility diagnoses at all.
Not only are our veterans’ infertility diagnoses most likely not being fully accounted for, but they also may not be considered service-connected even if they may very well be a consequence of their service. Evidence suggests that environmental pollutants such as chemicals and radiation may have adverse effects on fertility (Homan, Davies, & Norman, 2007). According to the VA, deployed service members are potentially exposed to various toxins and pollutants by way of burn pits, dust, asbestos, and other factors (2016). Other occupational hazards such as intense vibrations while riding in military vehicles or air craft, and operating certain types of heavy machinery could also have a negative effect on fertility (Penkov & Tzvetkov, 1999).
In addition to environmental factors, deployed service members are exposed to significant amounts of stress. According to Sharma, Biedenharn, Fedor, & Agarwal, psychological stress has a significant impact on sperm density, and physical stress also has implications on female fertility (2013). The American Psychological Association (APA) also notes that stress can have negative effects on both the male and female reproductive systems, as well as the endocrine system which produces the hormones related to fertility (2016).
According to Brundage, the percentages of female service members diagnosed with infertility were significantly higher in those that had deployed for periods exceeding nine months, compared to those who stayed in theater for less time (2013). These percentages also increased with each deployment, meaning that for female service members who deployed more than once, the infertility rate climbed higher after each deployment. This fact alone should be a significant indicator that in some, if not many cases, deployment does have a negative effect on fertility.
Unfortunately, the policies being proposed to assist veterans with reproductive disabilities focus only on coverage for veterans who are given service-connected disability ratings for their infertility; they do not address the severe underestimation of infertility diagnoses among veterans, or the lack of research to help determine potential causes for said diagnoses.
RECOMMENDATION
With the increase in infertility among OIF and OEF veterans, our country has a responsibility to ensure that these men and women are being properly diagnosed and treated for their reproductive disabilities. Although the VA may prioritize certain physical ailments over reproductive disorders, it is still important to assess and diagnose infertility, as diagnosis is the first and most important step to determining service-connection for these disabilities. The VA should include questions related to fertility on patient questionnaires in order to ensure that the providers take note of any reproductive issues the patients may be having, and address those issues.
There also needs to be more research on the effects of factors such as environmental toxins, occupational hazards, and psychological and physical stress as they relate to reduced fertility among OIF and OEF veterans. Many studies attempt to correlate multiple illnesses and disorders to these factors, but there are none that specifically look at their effects on fertility.
The proposed bills will allow many more veterans to get the treatment they are entitled to only if they are actually being diagnosed and given service-connected ratings. Until that happens it is highly likely that the people these bills are intended to help will receive no help at all.
References
- American Psychological Association. (2016). Stress effects on the body. Retrieved from http://www.apa.org/helpcenter/stress-body.aspx
- Chandra, A., Copen, C., & Steven, E. (2013). Infertility and impaired fecundity in the United States, 1982–2010: Data from the National Survey of Family Growth (67). Retrieved from National Center for Health Statistics website: http://www.cdc.gov/nchs/data/nhsr/ nhsr067.pdf
- Department of Veterans Affairs. (2016). Military exposures – Public health. Retrieved from http://www.publichealth.va.gov/exposures/
- Homan, G., Davies, M., & Norman, R. (2007). The impact of lifestyle factors on reproductive performance in the general population and those undergoing infertility treatment: A review. Human Reproduction Update, 13(3), 209-223. doi:10.1093/humupd/dml056
- Katon, J., Cypel, Y., Raza, M., Zephyrin, L., Reiber, G., Yano, E. M., Schneiderman, A. (2014). Self-reported infertility among male and female veterans serving during Operation Enduring Freedom/Operation Iraqi Freedom. Journal of Women’s Health, 23(2), 175-183. doi:10.1089/jwh.2013.4468
- Mattocks, K., Kroll-Desrosiers, A., Zephyrin, L., Katon, J., Weitlauf, J., Bastian, L., Brandt, C. (2015). Infertility care among OEF/OIF/OND women veterans in the Department of Veterans Affairs. Medical Care, 53, S68-S75. doi:10.1097/mlr.0000000000000301
- Penkov, A., & Tzvetkov, D. (1999). Effect of vibrations on male reproductive system and function. Central European Journal Of Public Health, 7(3). Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10499149
- American Society for Reproductive Medicine. (2013). Definitions of infertility and recurrent pregnancy loss: A committee opinion. Fertility and Sterility, 99(1), 63. doi:10.1016/ j.fertnstert.2012.09.023
- Sharma, R., Biedenharn, K. R., Fedor, J. M., & Agarwal, A. (2013). Lifestyle factors and reproductive health: taking control of your fertility. Reprod Biol Endocrinol, 11(1), 66. doi:10.1186/1477-7827-11-66