This article by Kelly Kennedy originally appeared on TheWarHorse.org, a nonprofit investigative news organization focused on covering the Departments of Defense and Veterans Affairs.
Genevieve Chase accomplishes everything she attempts.
She made first sergeant in 13 years in the Army reserves and started American Women Veterans, an advocacy organization. She served twice in Afghanistan, earning a Bronze Star, a Combat Action Badge, and a Purple Heart. She also testified before the U.S. Senate about her experiences in Afghanistan and the care needed for women veterans, and she was inducted into the Army Women's Hall of Fame.
In the military, she learned Pashto and was an intelligence soldier in Afghanistan.
But, like a lot of military women, one dream eludes her: She hasn't been able to get pregnant.
"I think if there's one thing I could tell young women in the military today who might someday want children, it's freeze your eggs," said Chase. "Nobody tells you how much of a problem infertility is."
While the fee for storing eggs is costly -- about $600 a year after $6,000 to $10,000 to retrieve one cycle of eggs -- Chase, who is 41, and other military women worry that serving in the armed forces often means putting off having a family until the women are deemed by doctors to be "geriatric" in terms of pregnancy.
A recent survey suggests that infertility issues may be higher for women who have been in the military. The research shows that military women face three known causes for infertility: exposure to toxins, prescriptions for psychiatric medications -- which are first-line treatment for veterans with PTSD -- and a higher-than-average rate of reported sexual trauma.
Chase and others say that, if the military wants to attract and keep female recruits, officials must pay more attention to the needs of military women.
Sarah Meadows, a senior sociologist for Rand Corporation who has researched the health issues of service members, said a low ratio of women in the military may play a role in the limited attention paid to infertility issues. "I think in part, historically it's because women have made up 20% or less of the military," she said. But Meadows added that the Defense Department "is now clearly interested in women's health and well-being" because women make up a larger percentage of the force than they have in the past, as well as being able to serve in any role. "If women are unhappy with the services they're provided or how they're being treated, they're not going to stay," she said.
Women Not Fighting for It
As has happened in the past, women have a tendency to do just as they've been trained: They suck it up and drive on.
"To get women to sit down and talk about their struggles is hard," said Chase. "We let things go and we move on."
But, as fertility issues caught up with her, Chase decided it was time to speak up. "Now I'm very open," she said. "I told my commander, 'Sir, I'm getting knocked up. I don't have a family and you guys all do.'"
Though her commander wasn't thrilled about the idea of losing his first sergeant just before a deployment, Chase said she believes the truth of her words hit home: It would simply not occur to the majority of the men in her unit to delay having families.
And, she said, because it doesn't often occur to the military to think about how the female anatomy is different from the male -- for example, women are born with all the eggs they will ever have -- she wondered if anyone was looking at what women's bodies have been exposed to as they faced the toxins and stressors involved in going to war.
What the Research Shows
Researchers have documented the infertility issues of men at higher rates: A survey of male and female combat veterans of the recent wars in Iraq and Afghanistan found about 14% of 16,056 men surveyed and 16% of 4,314 women surveyed have dealt with infertility. A Veterans Affairs study found that male veterans with Post Traumatic Stress Disorder are more likely to experience sexual dysfunction, while a study released in April found that men with post-traumatic stress disorder have overall rates of erectile dysfunction of 85% compared to rates of 22% in veterans without PTSD.
For women, there's less available research, and it tends to focus on both men and women. For example, a study sponsored by Veterans Affairs in 2015 found that both men and women with PTS are more likely to have problems with intimacy because the brain connects arousal with aggression, which can leave them feeling fearful or threatened rather than open to pleasure.
While women deal with the same factors as men -- combat injuries and exposures -- they also face another threat that may play into infertility rates: sexual assault. As many as one in four women veterans have reported military sexual trauma, according to Disabled American Veterans.
But there is some research specific to women: One study found that 47% of women seeking treatment for vaginal pain had experienced physical or sexual trauma, and 31% had symptoms of PTS. A 2016 study of female veterans interviewed by phone found that more female veterans have had hysterectomies at much younger ages -- 35 versus 43 years old -- than civilians and that those who experienced rape in their lifetimes were more likely to have the procedure.
And in 2018, one in three of the 799 veterans and current service women who responded to a 2018 Service Women's Action Network survey said they experienced problems with infertility.
Ellen Haring, former chief executive officer of Service Women's Action Network, SWAN, said women surveyed believed the problems were connected to exposure to toxins on deployment and on their jobs -- as did the men who also called in to talk about infertility issues.
Haring spoke at a California Veterans Affairs webinar last August and said speakers from VA agreed there is a shortage of research on women's infertility and that military sexual trauma came up as one of the possible causes. One presentation slide, from Jodie Katon, research assistant professor at VA's Puget Sound Health Care System, showed as many as half of women treated at VA facilities have been sexually assaulted at some point in their lives. (About 22% report military sexual trauma.)
But Haring said she hopes to hear more soon.
"These are women who work at the VA who care about this issue," she said.
Meadows said Rand recently conducted a Defense Department-sponsored survey of military women's reproductive health.
"We realized there hasn't been a DoD-wide survey of women's health since 1989," Meadows said.
The latest survey includes sections on infertility and pregnancy. But even with funding, Meadows said it's hard to properly study women's infertility in the military.
"You don't know if you're infertile unless you're trying to have a child," she said. "There are a lot of young women in the military who are not trying to have a child, so there's nothing to compare it to."
This is especially true as women say they plan to wait until their military careers are over before they try to conceive, she said.
Meadows expects the survey to be completed early this year, and then it will probably take about nine months to be released.
Waiting Out Their Careers
Chase joined the military in 2003, when she was 25, and figured she would never have kids.
"You're constantly thinking, 'If I get pregnant, they're going to think I'm trying to get out of deployment," she said. "And I'm the first sergeant. It's an important job."
But in 2006, a suicide bomber drove his car head-on into the vehicle in which she was riding in Helmand Province, Afghanistan. After much consideration, shaken and amazed at the series of events that kept her team alive, she changed her mind about children.
"I just thought, 'I'm so lucky,'" she said. "I thought, 'You know, Eve, it's time to have kids. I want to experience that kind of love.'" She's going through her first cycle of in vitro fertilization after several failed attempts to get pregnant. "I'm trying not to get my hopes up," she said.
With her current boyfriend, she has legally set up terms that she has full custody, that he won't be financially responsible unless he wants to be, and that the child will take her name.
Back in 2008, "I had what they call a 'chemical' pregnancy where your body thinks it's pregnant," she said. "I was so excited, because I thought I was pregnant, but I wasn't."
Since then, nothing.
"Trying to adopt in this country is ridiculous, and it's about the same amount of money as IVF," she said. "Trying to adopt as a single military person? It's impossible. If I get pregnant, I have to go around and ask all of my friends if they can take care of my child if I deploy."
She's also on the fast track to make sergeant major.
"But I know I can't do both," she said. "I feel like it would be a disservice to my soldiers. As angry as it makes me to admit that, I have to be honest with myself." Of course, there's an irony in the admission: In the world of military men, there's a belief that having a family can help one's career. It shows stability. It shows you're a provider. It shows you're probably serious about sticking around and making rank.
Her commander was supportive, she said.
"He said, 'Yeah, top, you should do it," she recalled. "But I know it was hard. He had to be thinking, 'If she has a baby, she's not going to be here.'"
Since then, she has moved to a full-time staff position at the Pentagon on active orders. She said that, if she gets pregnant, those orders will likely be canceled.
Chase enrolled in the military's IVF program, but she said her military doctors told her they do not recommend freezing eggs after age 30.
"There are programs for us, but they max out at age 42," she said. "I'm 41. I didn't know."
The military's IVF program is half-cost and constantly overbooked, she said. In September, she learned her IVF procedure had failed. "But this is it," she said. "After this, it's $15,000 to $20,000. Tricare doesn't cover anything but the diagnosis. If you do have issues, they'll treat the issue, but not the artificial insemination and IVF."
The military does not cover freezing and storing eggs, though a new bill, sponsored by Sen. Patty Murray (D-WA), would allow troops to freeze their eggs at no cost before deploying and store them for up to one year after leaving service. The VA will cover IVF if a woman can prove her infertility is service-connected, an impossible feat for most women.
Heidi Agostini, 38, a former Marine who managed military journalists in Helmand Province in 2010, went in for intrauterine insemination last August.
"I found out that round wasn't successful on my anniversary," she said. "It's all been very depressing."
She began her sixth -- and final -- round last November.
Initially, when she could not get pregnant, she was told her naval hospital did not offer infertility treatment, so she paid for two unsuccessful intrauterine insemination cycles herself, costing her $5,000. During a checkup at the naval hospital, her doctor said the hospital did offer the treatment.
"I started going to Naval Medical Center San Diego, about an hour away from the base," she said. "It was too hard to take time off work, especially since you don't know until the last minute if your ovaries or follicles are ready for triggering."
She quit after one month.
VA sent her to an infertility specialist, where her issues were deemed service-connected. But after her appointments were canceled without VA letting her know, she decided to go through her husband's health insurance.
Chase suspects getting blown up may have affected her body's ability to procreate. She was diagnosed with a brain injury, along with suffering from other health issues and fertility issues that no one else in her family has dealt with.
"I don't know if the TBI or the blast would contribute, but the blast was significant enough to affect my brain," she said.
She may be onto something. According to a study published in JAMA Pediatrics, about a quarter of girls and women studied with sports-related head injuries had abnormal periods following the injury because of a disruption of the reproductive system, leading to concerns about the long-term effects of those injuries.
And several recent studies point toward environmental factors, such as the dioxin found in burning trash or PCBs, causing endometriosis, according to the Endometriosis Association. The burn pits in Iraq and Afghanistan are known to have released dioxins, and endometriosis also causes infertility. TBI is also known to cause changes in sexual desire, decreased sperm production, and sexual dysfunction.
But Chase also wonders about what she was exposed to while deployed. Plastic bottles sat on pallets in the hot sun, leading to concerns about the chemical bisphenol A leaching into the water she drank. A recent study found BPA may cause infertility, as well as eggs with either too many or too few chromosomes.
She also ran laps around the burn pit at Bagram Airfield, in Afghanistan, which released dioxin, as well as other toxins, into the air she breathed.
"When you're pregnant, you can't go to the field because of exhaust fumes and radio waves," she said. "We have pretty strict regulations, like you can't work more than eight hours a day, which I am grateful for. But when you're deployed, you're exposed to that stuff 24/7: pollution, dust, working 12-hour days, stress."
Agostini also believed stress had an effect and said she felt as if her body had aged 10 years in the seven months she was deployed.
"I was fighting a suicidal depression; I struggled to make Marine Corps weight standards; and I couldn't get pregnant," she said. "I tried to see a doctor several times with Naval Health, but you can't just make a doctor's appointment: You have to go through the Battalion Aid Station, often manned by immature male corpsmen while you're surrounded by male Marines. So it was intimidating to go in there and say, 'Hey. I can't get pregnant, and I keep gaining weight. And oh, by the way, I want to off myself.'"
When she finally did seek mental health help, she said the battalion aid station gave her the 1-800 number for Military OneSource.
Two years later, she went to see a doctor and was diagnosed with polycystic ovary syndrome, PCOS, which explained the weight gain and infertility.
"When I said I felt something was wrong with my body, people didn't believe me," said Agostini.
She said she's not the only one. "I still talk to several female Marines I deployed with who struggle with infertility and who have been pushed aside from the military health care system."
As more women veterans take psychiatric medications, they find themselves faced with another issue: lack of interest.
"I feel like I lost my 30s," said Angela Peacock, 40, who served in Baghdad while in the Army and who has been diagnosed with PTS. "I've been on 43 meds in 13 years. At one point, I was taking 18 medications."
She suspects the medications affected her sex drive and mourns the loss of the "butterflies" she remembers feeling in her 20s. Since 2006, she said she hasn't been in any relationships. "The longer I was on meds, the less I felt anything sexual," she said.
According to Harvard Health Publishing, the issue is double-edged because antidepressants can cause a loss of libido -- and so can depression. Between 35% and 50% of people with depression experience sexual dysfunction, and selective serotonin reuptake inhibitors, SSRIs, used to treat depression may decrease libido in approximately 20% of patients.
Research so far has been mixed about how SSRIs affect a woman's fertility, with six of seven studies finding no issues and one finding increased pregnancy rates, according to a paper in the Harvard Review of Psychiatry.
Chase believes her depression -- she thought about killing herself after both deployments -- added to the stress her body went through.
"Generally speaking, men tend to externalize stress often as anger," she said. "Women internalize it. I wonder if there are autoimmune issues because of that. Weight gain. Disabilities. The drugs they give us. These are issues nobody cares about because they expect us to take care of ourselves, but that's hard when you're holding it all in."
Advocating for Ourselves
Haring and SWAN took the information they gathered from the survey to members of Congress, including more than 30 visits since February 2019.
"I think we've accomplished what we intended with this report, which is to get some more research done," said Haring. "We'd like for people to look at medical records, to look at the data and see how many people have been diagnosed or compensated. Publish the results. If it is exposure, let's give them the benefits they deserve."
Chase, who says her greatest concern has always been her soldiers -- both men and women -- said her organization is working on some potential legislative changes, though the board is still figuring out what those recommendations would look like.
"I may not have a baby," she said. "It may not work out for me. But I'm going to work on this and do what I can to raise awareness. If I can help someone else not make the same mistakes I have in waiting and putting it off, then something good will have come from this."
Kelly Kennedy is an award-winning journalist and author of They Fought for Each Other: The Triumph and Tragedy of the Hardest Hit Unit in Iraq. Kelly served in Iraq, Kuwait and Saudi Arabia during Operation Desert Storm in 1991; and then in Mogadishu, Somalia, in 1992 and 1993. She is the only American woman to have both served in combat in the U.S. military and covered U.S. combat as a civilian. Her website is KellyKennedy.net.