Men in the Military Face Unique Fertility Challenges

Editor's note: The first article in this series delved into female infertility in the military. It also covered many basics about the healthcare system and what support is (or is not) available to military members facing infertility. Read that article to get an overview of the situation. For this article, we focus specifically on male infertility in the military.

People serving in the military experience unique occupational exposure to physical and psychological trauma that is often unparalleled in civilian society.

Male military veterans have a greater risk of infertility than the general population, with an estimated 13.8 percent lifetime prevalence, according to a 2018 study published in the journal Translational Andrology and Urology. However, the same study points out that male military veterans are less likely to seek or receive infertility care than their female counterparts.

Similar to female infertility, the cause of male infertility in active-duty soldiers is multifactorial and complex.

Researchers are still trying to understand the precise relationship between military service and male infertility, explained Joshua Halpern, M.D., a urologist and staff surgeon at the Jesse Brown VA Medical Center in Chicago and an assistant professor at Northwestern Medicine who specializes in men's health, sexual function and fertility.

He said military couples have unique concerns and considerations regarding fertility. They can experience delays in family building due to the demands of military service, including when men and women on international tours of duty are separated from their partners for extended periods and unable to make attempts at conception.

Those attempts are limited to a small window. To optimize chances of conceiving naturally, a couple needs to target the ovulation date of the female partner, said Ramy A. Ghayda, M.D., M.P.H., an assistant professor of urology at Case Western Reserve University School of Medicine in Cleveland. Ideally, they need to have daily unprotected sex two days before ovulation, the day of ovulation and one day after ovulation. This is referred to as the fertile window, during which the probability of pregnancy is the highest.

"If you miss this fertile window, it is virtually impossible for a couple to conceive naturally," said Ghayda, who is also the chief medical officer at Legacy, a fertility company in Boston that provides semen test kits, sperm-freezing services and other fertility help.

With deployments and irregular schedules, active-duty families do not have the luxury of timing intercourse, which can lead to trouble with conception.

"One mitigation strategy is the use of frozen sperm for in vitro fertilization [IVF] or intrauterine insemination [IUI] to overcome the geographical dislocation," Ghayda said.

However, TRICARE, the military healthcare program, does not cover IVF, IUI or any noncoital reproductive procedures.

In addition, the spouses and partners of active-duty service members may be under pressure to capitalize on their limited chances to reproduce, said Roger Shedlin, M.D., J.D., president and CEO of WINFertility, a family-building solutions company headquartered in Greenwich, Connecticut. Thus, they have a higher incidence of twin births than the general population, primarily because military families often turn to assisted reproductive technologies (ART) to help with family building.

"Because twins and higher-order multiple gestations are more likely to have a low birth weight and other complications, they require higher NICU [neonatal intensive care unit] costs than singleton births," Shedlin added.

Halpern said men in roles that increase their exposure to any of the following risk factors may be at increased risk for infertility:

• Extreme heat
• Radiation
• Spinal cord injury
• Traumatic brain injury
• Traumatic injury to the genitourinary tract

"For example, one study found that nuclear submarine workers were more likely to have infertility compared to other military personnel," Halpern added.

Interestingly, a report carried out by the Military Health System found overall rates of male infertility diagnoses were highest among Army or Air Force members, and lowest among the Marine Corps.

"We know that male members of the military who are actively serving or are veterans have lower semen parameters," Ghayda said, noting it has been shown repeatedly over the years that men who serve in the military have reduced semen quality compared with the general population. "We don't know exactly why this is, but it is likely due to multiple factors, such as high levels of stress, exposure to toxins [such as] agent orange, burn pits and radiation from weapons, and war-induced injuries."

Blast and bullet injuries to the genitals are significant concerns for men on active duty in a war zone. The Department of Defense even introduced new groin protectors to better shield soldiers from genital injuries, said Patricia Hayes, Ph.D., chief officer of women's health for the Veterans Health Administration.

"But we don't know the long-term effect that these have had on blast injuries to the genitourinary tract and, therefore, infertility," Hayes said.

Veterans deployed for Operation Enduring Freedom, Operation Iraqi Freedom or Operation New Dawn seek and receive reproductive health treatment or assessment at what appears to be a higher rate than military members who were not deployed on these operations, according to a 2017 study published in the journal Military Medicine. There is no clear conclusion as to why. However, researchers observed that a diagnosis of major depression or post-traumatic stress disorder (PTSD) in veterans was associated with decreased sperm motility.

Halpern explained that PTSD and other mental health disorders could also impact male fertility. One study of veterans found those with a history of PTSD or depression had worse semen quality compared to those without a history.

"It's not clear exactly why, but we do know that stress can impact hormone levels, which could be one mechanism," Halpern said.

Ghayda said both depression and anxiety can cause erectile dysfunction (ED) or ejaculatory dysfunction, which can hinder a man being able to ejaculate during sex and, therefore, impact natural conception.

In addition, medications used for mental health, such as selective serotonin reuptake inhibitors (SSRIs), are mostly safe in relation to male fertility but can negatively impact sexual function, Halpern said. This can be an issue for couples attempting to conceive. But importantly, veterans should not discontinue these medications for any reason without consulting their physician.

There are two types of health coverage available to serving military members and veterans:

1. TRICARE (Department of Defense) is the health coverage available to active-duty personnel, reserves, National Guard members and retirees.
2. Department of Veteran Affairs (VA) is the health coverage available to discharged veterans (nonretirees).

TRICARE covers basic diagnostics for fertility for active-duty military members. However, it does not cover IVF or most other fertility treatments unless the service member had a serious illness or injury while on active duty that caused them to lose natural reproductive ability.

Despite the research that shows sperm quality can be affected by military service and male military members often have lower semen parameters, fertility preservation is not covered by TRICARE.

When veterans leave the military, they can instead access health care provided by Veteran Affairs, which is similar to that of TRICARE. Identifying a facility that can provide the needed infertility services can sometimes be a challenge, and some veterans may not have access to care at a facility close to their home, Halpern noted. Some infertility treatments may require a referral to a community provider, and others may not be covered altogether.

"The VA does provide assistance in navigating infertility diagnosis and treatment, so anyone who encounters barriers in accessing care should not hesitate to reach out to their provider or to the VA directly," Halpern said.

John Crowley, the head of military affairs at Legacy, explained that because military training and combat deployment are inherently risky, he focuses on working with military service members proactively by offering free semen analysis and cryopreservation.

"Reproductive health is an important component of military readiness and, consequently, a matter of national security," Crowley said.

Legacy has partnered with several military-focused organizations, including:

• The Military Family Building Coalition (read more about it here). The Washington, D.C.-based organization supports active-duty military members facing fertility and family-building challenges.
• The Operation Baby Foundation. This veteran-founded nonprofit organization based in Arlington, Virginia, provides grants of up to $5,000 to military couples diagnosed with infertility to assist with treatment, surrogacy or adoption costs.

Military service can be dangerous and incredibly stressful, and have a significant impact on sperm quality and fertility. Freezing your sperm is a safe way to protect fertility and plan for the future. With unpredictable deployments, the benefits of cryopreservation are invaluable for men serving in the military.

Shedlin said that in the private sector, where family-building services are typically offered, companies save millions of dollars on employee medical expenditures, have improved recruitment/retention and see increased productivity after adopting a managed fertility benefit. Federal employers, including the military, have yet to adopt such benefits. In Congress, U.S. Sens. Tammy Duckworth, D-Ill., and Patty Murray, D-Wash., introduced the Veteran Families Health Services Act to offer comprehensive fertility healthcare coverage for military families.

"Men looking to join the military need to be aware that fertility and family building may be an issue," Ghayda said. "It is vital to open up discussion in this area, so they can discuss family building before deployments and proactively take steps to protect or manage their fertility health."