Infertility among male UK veterans of the 1990-1 Gulf war: reproductive cohort study

Hidden trauma: shedding light on the relationship between gun violence and infertility

Objective

To study the existing data on the relationship between penetrating abdominopelvic injuries and fertility guidance on managing fertility concerns of these patients using a case report and scoping review.

Design

Case report and scoping review.

Setting

Not applicable.

Patient(s)

People who have experienced abdominopelvic trauma from gun violence or in the course of combat.

Intervention(s)

None.

Main Outcome Measure(s)

We extracted case report data from electronic health records. We performed a scoping review using PubMed and Scopus. Search terms were related to penetrating abdominopelvic trauma, gunshot wounds (GSW), war, and fertility/infertility. We evaluated the study year, age and race, mechanism of injury, fertility outcomes, and how fertility concerns were addressed with patients who experienced penetrating abdominopelvic trauma.

Result(s)

In the case report, the couple had 10 years of infertility. The male partner experienced an abdominopelvic GSW before attempting to conceive. After evaluation, he was diagnosed with retrograde ejaculation. He recalled being advised that his GSW might affect his future fertility. The couple has discontinued care.

For the scoping review, 879 sources were identified and 25 studies were included in the review. Among the studies conducted in the United States, most patients included were African American.

Eighty-eight percent (n = 22) of the sources acknowledged the importance of fertility or used fertility-related outcome measures. One study commented on how to address fertility concerns with victims of abdominopelvic penetrating trauma.

Conclusion(s)

There is a paucity of data on the intersection of penetrating abdominopelvic injuries and fertility or guidance on how to discuss fertility issues with patients.

Trauma exposure, PTSD and indices of fertility

Background: Trauma exposure and posttraumatic stress disorder (PTSD) has been linked with numerous adverse health conditions, but it is unclear if trauma exposure and PTSD are associated with infertility. The objective of this study was to examine the contributions of trauma exposure and PTSD symptoms in predicting length of time to conception and utilization of infertility testing and treatment.Participants: Two hundred and forty-six trauma-exposed females (M_age = 36.69, SD = 10.82, Range = 19-59; 62.2% white) who had either been pregnant or had tried to become pregnant were included in the study. Participants' level of trauma exposure and PTSD symptoms were examined in relation to length of time to conception and use of infertility testing and treatments.Result(s): Infertility was present in 16.7% of the sample, 12.4% of participants had seen a doctor regarding infertility and 9.9% of participants had undergone fertility testing or treatments. PTSD was significantly related to longer length of time to conception, use of infertility testing and treatment and number of infertility testing and treatments, after controlling for covariates. Cumulative trauma, defined as number of traumatic exposures, was marginally related to use of infertility testing and treatments, but not to length of time to conception or number of infertility testing and treatments. Neither cumulative trauma nor PTSD was associated with self-reported infertility diagnosis.Conclusion(s): PTSD, but not trauma exposure, may be a risk factor for reduced fecundity and increased use of infertility treatment and testing among women.

Impact of War on Fertility and Infertility

BACKGROUND

War causes more death and disability than many major diseases. There are few studies in the context of the deleterious impact of war on fertility potential; therefore, in this study, we tried to review articles about the adverse effects of war on male/ female fertility potential.

METHODS

In this study, a total of 183 articles related to the effects of war on fertility potential were examined by a systematic search using known international medical databases.

RESULTS

Among these studies, there were limited studies on the effects of war on female infertility and most studies examined the effects of war on sperm parameters and male infertility. The physical and psychological trauma of war can increase the risk of infertility in men and women. Presence of reproductive system toxins in weapons, stressful periods of war and direct damage to the reproductive system can impair the fertility of men and women. The way war affects male fertility is not clear, but the higher degree of stress during wartime seems to play an important role. Using reproductive toxicants during the war also increases the risk of impairment in reproductive function in men. Some studies have shown the harmful effects of Sulfur mustard as a war chemical toxin especially on sperm quality and male infertility. Oxidative stress induced by free radicals is a major mechanism for the direct effects of Sulfur mustard on male infertility.

CONCLUSION

The study of past research suggests that exposure to war may be an independent risk factor for reproductive disorders and infertility in men. For female infertility, war leads to menstrual dysfunction.

Self-reported infertility among male and female veterans serving during Operation Enduring Freedom/Operation Iraqi Freedom

BACKGROUND

Infertility is associated with psychosocial distress and is a growing public health concern. Our objective was to report the prevalence of lifetime history of infertility among men and women Veterans.

METHODS

We used data from the U.S. Department of Veterans Affairs National Health Study for a New Generation of U.S. Veterans, a nationally representative survey of Veterans serving during Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF). The primary dependent variables were self-reported lifetime history of infertility among Veterans and their partners, defined as trying unsuccessfully to become pregnant for at least 12 months, and seeking medical help for infertility. Multiple logistic regression was used to determine whether gender was associated with lifetime history of infertility or seeking medical help for infertility, after adjusting for sociodemographic and military characteristics. All analyses were weighted to account for the complex survey design and nonresponse.

RESULTS

Among the 20,370 Veterans (16,056 men; 4,314 women) in our final analytic sample, the prevalence of lifetime history of infertility was 15.8% for women and 13.8% for men. After adjusting for age, ever married, education, race/ethnicity, component, branch of service, and deployment to OEF/OIF, compared with men, women Veterans had similar odds of lifetime history of infertility (odds ratio [OR] 1.07; 95% confidence interval [CI] 0.94, 1.20), but increased odds of seeking medical help for infertility (OR 1.35; 95% CI 1.06, 1.72).

CONCLUSIONS

Women Veterans are more likely than their male counterparts to seek care for infertility, and given their increasing numbers, the demand for infertility evaluation and care within Veterans' Affairs may increase.

Deletion of murine choline dehydrogenase results in diminished sperm motility

Choline dehydrogenase (CHDH) catalyzes the conversion of choline to betaine, an important methyl donor and organic osmolyte. We have previously identified single nucleotide polymorphisms (SNPs) in the human CHDH gene that, when present, seem to alter the activity of the CHDH enzyme. These SNPs occur frequently in humans. We created a Chdh(-/-) mouse to determine the functional effects of mutations that result in decreased CHDH activity. Chdh deletion did not affect fetal viability or alter growth or survival of these mice. Only one of eleven Chdh(-/-) males was able to reproduce. Loss of CHDH activity resulted in decreased testicular betaine and increased choline and PCho concentrations. Chdh(+/+) and Chdh(-/-) mice produced comparable amounts of sperm; the impaired fertility was due to diminished sperm motility in the Chdh(-/-) males. Transmission electron microscopy revealed abnormal mitochondrial morphology in Chdh(-/-) sperm. ATP content, total mitochondrial dehydrogenase activity and inner mitochondrial membrane polarization were all significantly reduced in sperm from Chdh(-/-) animals. Mitochondrial changes were also detected in liver, kidney, heart, and testis tissues. We suggest that men who have SNPs in CHDH that decrease the activity of the CHDH enzyme could have decreased sperm motility and fertility.

Reproductive health and pregnancy outcomes among French gulf war veterans

Background

Since 1993, many studies on the health of Persian Gulf War veterans (PGWVs) have been undertaken. Some authors have concluded that an association exists between Gulf War service and reported infertility or miscarriage, but that effects on PGWV's children were limited.

The present study's objective was to describe the reproductive outcome and health of offspring of French Gulf War veterans.

Methods

The French Study on the Persian Gulf War (PGW) and its Health Consequences is an exhaustive cross-sectional study on all French PGWVs conducted from 2002 to 2004. Data were collected by postal self-administered questionnaire. A case-control study nested in this cohort was conducted to evaluate the link between PGW-related exposures and fathering a child with a birth defect.

Results

In the present study, 9% of the 5,666 Gulf veterans who participated reported fertility disorders, and 12% of male veterans reported at least one miscarriage among their partners after the PGW. Overall, 4.2% of fathers reported at least one child with a birth defect conceived after the mission. No PGW-related exposure was associated with any birth defect in children fathered after the PGW mission. Concerning the reported health of children born after the PGW, 1.0% of children presented a pre-term delivery and 2.7% a birth defect. The main birth defects reported were musculoskeletal malformations (0.5%) and urinary system malformations (0.3%). Birth defect incidence in PGWV children conceived after the mission was similar to birth defect incidence described by the Paris Registry of Congenital Malformations, except for Down syndrome (PGWV children incidence was lower than Registry incidence).

Conclusion

This study did not highlight a high frequency of fertility disorders or miscarriage among French PGW veterans. We found no evidence for a link between paternal exposure during the Gulf War and increased risk of birth defects among French PGWV children.

Environmental contaminants and human infertility: hypothesis or cause for concern?

Throughout the 1980s and 1990s the crude human birth rate (live births per 1000 population) declined, indicating reduced fertility and suggesting a potential decline in fecundity (the potential to conceive). Detection of environmental contaminants in human tissues, together with reports of a global decline in semen quality, further fueled speculation that human infertility rates are increasing and environmental toxicants are potentially important causal agents associated with this change. However, there is little compelling evidence to suggest that infertility rates amongst the general population have changed over time. Moreover, recent studies suggest a rise in the fertility rates. While several studies documented increased time to pregnancy (TTP) in exposed study populations, other investigators were not able to replicate these findings. Nevertheless, studies involving occupational exposure together with results from animal experiments lend support to the conclusion that environmental contaminants potentially adversely affect fertility. Consequently, the impact of exposure to environmental contaminants on human fertility remains controversial. To test the hypothesis that environmental contaminant exposure was associated with enhanced risk of infertility, data concerning trends in fertility and infertility rates were examined to assess the impact of exposure of developing gametes to environmental contaminants. The relationship between exposure and reproductive outcomes was then examined to illustrate the range of adverse effects for reproductive toxicants with data sets of divergent depth and reliability. Data showed that only a weak association between exposure to environmental contaminants and adverse effects on human fertility exists. However, it is postulated that evidence of chemical exposure and potential health consequences of these exposures highlight the need for further research in this area.

Civil war and male infertility in Lebanon

OBJECTIVE

To investigate the long-term impacts of the 15-year Lebanese civil war on male infertility.

DESIGN

Clinic-based, case-control study, using reproductive history and risk factor interview data and laboratory-based semen analysis.

SETTING

Two IVF clinics in Beirut, Lebanon, during an 8-month period (January-August 2003).

PATIENT(S)

One hundred twenty infertile male cases and 100 fertile male controls, distinguished by semen analysis and reproductive history.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Standard clinical semen analysis.

RESULT(S)

Infertile male cases were more likely than fertile controls to have lived through the Lebanese civil war and to have experienced war-related trauma (residence in bombing areas, participation in combat, injuries, kidnapping, and displacement from home). Cases had a 57% increase in their odds of exposure to civil war-related trauma.

CONCLUSION(S)

This case-control study demonstrates an association between the Lebanese civil war and male infertility. Wartime and postwar exposure to a number of potential reproductive risk factors-including toxins, injuries, and stress-is believed to be the main factor leading to this finding.

Reproductive health of male Australian veterans of the 1991 Gulf War

Background

Since the 1991 Gulf War concerns have been raised about the effects of deployment to the Gulf War on veterans' health. Studies of the reproductive health of Gulf War veterans have reported varied findings.

Methods

We undertook a cross-sectional study of male Australian Gulf War veterans (n = 1,424) and a randomly sampled military comparison group (n = 1,548). The study was conducted from August 2000 to April 2002. A postal questionnaire included questions about difficulties achieving pregnancy, pregnancy outcomes including live births, stillbirths, miscarriages and terminations; and for all live births gestation, birth weight, sex, and any cancers, birth defects, chromosomal abnormalities or serious health problems.

Results

Male Gulf War veterans reported slightly increased risk of fertility difficulties following the Gulf War (odds ratio [OR] 1.4; 95% confidence interval [CI] 1.0–1.8), but were more successful at subsequently fathering a child (OR 1.8; 95% CI 1.3–2.6). The study groups reported similar rates of pregnancies and live births. There was no increased risk in veterans of miscarriage, stillbirth, or terminations. Children of male Gulf War veterans born after the period of the Gulf War were not at greater risk of being born prematurely, having a low birth weight, or having a birth defect or chromosomal abnormality (OR 1.0; 95% CI 0.6–1.6). The numbers of cancers and deaths in children were too small to draw any firm conclusions.

Conclusion

The results of this study do not show an increased risk of adverse reproductive outcome in Australian male Gulf War veterans.

Reproductive health of Gulf War veterans

In this review we summarize the scientific literature on reproductive health following deployment to the first Gulf war by armed service personnel. All the studies examined had methodological limitations, making interpretation difficult. Nonetheless we conclude that for male veterans there is no strong or consistent evidence to date for an effect of service in the first Gulf war on the risk of major, clearly defined, birth defects or stillbirth in offspring conceived after deployment. Effects on specific rare defects cannot be excluded at this stage since none of the studies had the statistical power to examine them. For miscarriage and infertility, there is some evidence of small increased risks associated with service, but the role of bias is likely to be strong. For female veterans, there is insufficient information to make robust conclusions, although the weight of evidence to date does not indicate any major problem associated specifically with deployment to the Gulf. None of the studies have been able to examine risk according particular exposures, and so possible associations with specific exposures for smaller groups of exposed veterans cannot be excluded. We suggest that the way forward to address the question of veterans' reproductive health with confidence in the future is prospective surveillance following deployment. Anything less will result in further problems of interpretation and continued anxiety for parents, as well as prospective parents, in the armed forces.

Self-reported reproductive outcomes among male and female 1991 Gulf War era US military veterans

BACKGROUND

Following the 1991 Gulf War, some veterans expressed concerns regarding their reproductive health. Our objective was to assess whether an association exists between deployment to the 1991 Gulf War and self-reported adverse pregnancy outcomes.

METHODS

Using a modified Dillman technique with telephone follow-up, we conducted a survey via a postal questionnaire from February 1996-August 1997 to compare selected reproductive outcomes among 10,000 US veterans deployed to the 1991 Gulf War with those of 10,000 nondeployed Gulf War era veterans.

RESULTS

A total of 8742 individuals responded to the survey, a response rate of 51 percent. Using multivariable analyses, results showed no differences in number of reported pregnancies between Gulf War veterans and nondeployed veterans. Among 2233 female and 2159 male participants, there were no differences in birth weight of infants born to Gulf War veterans compared with nondeployed Gulf War era veterans. In multivariable models, male and female Gulf War veterans did not significantly differ in risk for ectopic pregnancies, stillbirths, or miscarriages when compared with nondeployed veterans of the same era.

CONCLUSIONS

These results do not suggest an association between service in the 1991 Gulf War and adverse reproductive outcomes for both male and female veterans during the 4 years after the war.

Multi-symptom illnesses, unexplained illness and Gulf War Syndrome

Explanatory models for the increased prevalence of ill health in Gulf veterans compared to those not deployed to the Gulf War 1990-1991 remain elusive. This article addresses whether multi-symptom reporting in Gulf veterans are types of medically unexplained symptoms and whether the alleged Gulf War Syndrome is best understood as a medically unexplained syndrome. A review of the epidemiological studies, overwhelmingly cross-sectional, describing ill health was conducted including those that used factor analysis to search for underlying or latent clinical constructs. The overwhelming evidence was that symptoms in Gulf veterans were either in keeping with currently defined psychiatric disorders such as depression and anxiety or were medically unexplained. The application of factor analysis methods had varied widely with a risk of over interpretation in some studies and limiting the validity of their findings. We concluded that ill health in Gulf veterans and the alleged Gulf War Syndrome is best understood within the medically unexplained symptoms and syndromes constructs. The cause of increased reporting in Gulf veterans are still not clear and requires further inquiry into the interaction between sociological factors and symptomatic distress.

A higher risk of congenital anomalies in the offspring of personnel who served aboard a Norwegian missile torpedo boat

BACKGROUND

In the 1990s, congenital anomalies were reported among children whose fathers had served aboard a Norwegian missile torpedo boat (MTB). The Royal Norwegian Navy asked the University of Bergen to look into this problem as one part of a general health and work environment surveillance.

AIMS

To estimate any increased risk of having children with congenital anomalies and having stillborn children among the offspring of workers that had served aboard the MTB and to investigate possible differences in exposure and other risk factors between these groups.

METHODS

Data from a cross-sectional study among all current employees of the Norwegian Navy (n = 2265, response rate 58%) were analysed.

RESULTS

The prevalence ratio of having a child with congenital malformations associated with working on the ship was 4.0 (95% CI 1.9 to 8.6). The prevalence ratio of having a child who was stillborn or died within one week was 4.1 (95% CI 1.7 to 9.9).

CONCLUSION

Service aboard the MTB was associated with an increased risk of having children with congenital birth defects and having children that were stillborn. The causes of these findings are unknown.

Health consequences of the first Persian Gulf War on French troops

Since 1993, many studies on the health of Persian Gulf War Veterans (PGWV) have been undertaken. These studies have concluded that there has been an increased mortality due to external causes, no excess of recognized diseases, and no effect on PGWV children. When compared with the non-deployed, PGWV have reported a higher frequency of infertility as well as different symptoms, but a specific Gulf War syndrome was not identified. In October 2000, the French government asked an independent working group to analyse the scientific literature on PGWV health. The group concluded that an exhaustive study of French PGWV was to be undertaken. The objectives of this study were to describe the exposures of PGWV in the operations theatre, to report on the symptoms and diseases that occurred in PGWV and their children during and after the military campaign, and to explore the possibility of a Gulf War syndrome. This exhaustive cross-sectional study, which included all civilians and troops who served in the Gulf from August 1990 to July 1991, began in January 2002. Data were collected by postal self-administered questionnaires. A standardized clinical evaluation was performed by 27 clinics of occupational diseases and nine military hospitals. Symptoms and diseases which appeared after the campaign are described. To date, among 20,261 PGWV, 5,666 participated in the study (28%). The most frequent symptoms described since the return from the Gulf were headaches (83%), neurological or psychological symptoms, and back pain. Apart from well-known symptoms associations (respiratory, neurocognitive, psychological and musculo-skeletal syndromes), no other cluster was highlighted by our analysis.