E106: The Environmental Domain of Family Planning

Kirtly: How does your environment affect your family planning plans? Welcome to the 7 Domains of Family Planning, and we're going to talk about the environmental domain. It's a big topic. How does your physical environment affect your fertility? How does where you live affect your family planning options?

I'm Dr. Kirtly Jones from Obstetrics and Gynecology at the University of Utah. My specialty was reproductive endocrinology, which had infertility and contraception, big family planning areas, as part of my research and clinical practice.

And with me is Dr. Katie Ward, my partner in crime here. Katie has a Doctorate in Nursing Practice and a PhD in anthropology. Katie and I met a generation ago in a family planning clinic.

So this is going to be a two-part conversation. The first will be how one's environment inside and out affects their fertility. This has been a research concern of mine over the years, the role of air pollution in increasing spontaneous abortion, and the role of environmental toxins in lowering sperm function, and the personal environment of diet and exercise and obesity in sperm function. So we're going to talk about that.

The second part will be where you live, your geographic environment and how it affects your family planning choices.

It takes eggs and sperm to make a baby, right? And there's been a lot of focus on female causes of infertility, including the presumption for thousands of years, that if women were barren, and that was the word that was used, not able to conceive a child, there was something wrong with her. But over the past 50 years, there's been more focus on male factors of infertility, and there's research about environmental causes of decreased sperm counts and function.

With us to talk about this is Dr. Kelli Gross. She's our urologist at the University of Utah with a special interest in male infertility. 

Kirtly: Thanks for joining us, Kelli, and helping just shine a little light on something we don't usually talk about too much. So how did you become interested in this field?

Dr. Gross: That's a good question. I don't think I have a good answer for that. I think in school, I knew I wanted to do surgery, and I explored all the different options and just really enjoyed being able to see quick changes that we do and see the good outcomes that we have in people. And not all subspecialties of surgery, I think, have that.

Kirtly: Well, the thing about the fertility part is that for men with severe sperm function problems, to be able to go into the testes and get a sperm and make a baby that way, it's something we could not do 20 years ago. You can come in, do your thing, and nine months later, they have a child, thanks to you. So thank you.

So why a men's urologist on a women's health podcast about family planning?

Dr. Gross: I think it's very common to underestimate the role of male fertility in the whole fertility journey. I think women really take charge in this space very frequently. And when they see people or are talking to people, the focus is really on them. But we have found that many times, about half of the time, we do see things that we can improve from the male standpoint. So there's a huge contribution from male partners to fertility.

Kirtly: Actually, now there's about 50/50. It's not exactly 50/50 because sometimes it's a combination of both, but I like the fact that now both couples are equally invested in an investigation in terms of doing the work-up, whereas the guy says, "Oh, I'm fine. I'm not going to get a sperm count."

So tell us a little bit about men's environment and how it affects conception and pregnancy planning and long-term reproductive health. This is the environmental issue, and more and more I think we're thinking about how men are the canaries in the coal mine. Their environment definitely affects their fertility. Can you talk about that?

Dr. Gross: I think the whole topic of the environment and fertility, particularly male fertility, is such a huge topic and so wide. So, of course, it's really hard for me to summarize.

There are things that are really clear and really big. For example, heat to the testicles. We know sperm is very sensitive to heat. So men that are doing hot tubs and saunas and things like that very frequently will often see very low sperm counts, and it can make a very big difference.

Now, if we're talking about things like environmental exposures, like chemical exposures, likewise there are some that we know have a really big effect, like chemotherapy. Now, most people aren't accidentally coming into contact with chemotherapy, but air pollution, for example, that one is a bigger topic, and that can be hard to really understand what effects are related specifically to that. With environmental exposures, there are usually so many different things going on.

Kirtly: Right. Well, I remember a study from San Antonio years ago looking at construction workers in San Antonio on roofs. They were roofers in the summer and looking at sperm quality, talking about testicular temperature. And after the summer, in the early fall, when sperm should be coming out that were made in the summer, their sperm counts fell.

So can physical stress. I mean, guys under enormous physical stress like army ranger training, their environment there can be associated with that drop in sperm quality.

And you're right, the air quality one is a complicated one. The same thing for pesticides and other things. But we actually published a study here in Salt Lake on looking at geocoding during parts of the year, meaning where people lived and what the air quality was. And many were giving multiple samples during the year. There wasn't a huge drop, but definitely a significant one for guys who lived in the poorest air quality. It's not just here, but Sao Paulo or China.

So what about lifestyle issues? I mean, that's part of the environment, the way guys are living or exercising or eating or . . .

Dr. Gross: I think that's the one we have the most control over, and it helps your overall health, so there's no downside to addressing those things. So every day, I'm talking about those modifiable lifestyle factors.

For things like wildfire smoke or air quality, for example, that's going to potentially track along with those different lifestyle things because there may be differences in socioeconomic status, for example, or access to care that could affect some of these outcomes.

But the things that we do know are that exercise is good for so many different medical conditions, for your overall health, for how you feel. Eating healthy, a good varied, balanced diet. I get asked all the time, "Are there certain foods that I should eat?" And the answer is no to that. But I do think that having a good variety of fruits and vegetables. And if you eat meat, lean meats, or other protein sources if you don't. Whole grains, for example. Cooking at home is the best that we can do, and I think really can have an effect on people's overall health.

I also tell people to get enough sleep. That's a really big one for hormones. We hear a lot about different endocrine disruptors. For example, things that can change men's hormones. And I'd say the thing that has a much bigger effect are those lifestyle things like sleep. Snoring, for example, has a huge effect on people's testosterone values.

Kirtly: And obesity. I think we really have seen some improvement in men's fertility when they have gone on a . . . whether they have bariatric surgery or whether they've taken drugs to drop a lot of weight. Men who carry more weight make less testosterone.

And you're not supposed to take testosterone. Taking testosterone will not improve your sperm count. Au contraire, right? If you take testosterone, it might really suppress your sperm count.

Well, there's been this thing about a 50% reduction in men's sperm numbers in the past 50 years. Do you have any thoughts about that? It's debated. I mean, right now, there's a lot of controversy, but . . .

Dr. Gross: That is controversial, but I would love to know. I wouldn't be surprised that some of those lifestyle things are a factor. I do think people are overall less active and overall eat more convenience-based diets than maybe they did 50 years ago. And again, there's the air quality, the exposure to microplastics, and things like that. We don't know the effect that those things have, but it's not implausible that they do have some effect.

Kirtly: Right. So we've got the environment that we live in, and we've got the environment that's in your home, and your eating. We are worried about pregnancy outcomes. We know guys with lower sperm quality sometimes have more miscarriages. So what can be done for men who are experiencing male factors? What do we do?

Dr. Gross: We're lucky that, for men, there's an easy way to test the semen. Now, it's not perfect, but a semen analysis gives us a lot of insight and can help us track over time.

And with an evaluation, we can really help personalize what those factors are for different people. So, for example, heat exposure can completely be associated with recurrent miscarriages. Heat to the testicles has been shown to really affect the genetic material of the sperm. So that can be a big factor.

It is not uncommon for men to have a varicocele, or dilated veins, that can . . . We think the way that it affects fertility is perhaps by trapping some heat in the testicle. So that's something that's modifiable. It's not environmental, of course, but that can be a really big effect that we see when we do fix.

Kirtly: Okay, Kelli. Boxer shorts or briefs? Do you get asked that question?

Dr. Gross: I do get asked that. We've actually done studies, not our group, but as a medical community, on that, and it does not seem to have an effect. So I tell people they can wear whatever underwear they want.

Kirtly: So guys can wear their boxers or their tighty-whities. They get to choose. Oh, thank goodness.

Well, what's your advice for young women who want to plan their families in the future? Or for young men, actually. So you've got a teenager and he's thinking about not making babies, but somebody who says, "Yeah, I really want to make a baby in a couple years from now. What should I be doing?"

Dr. Gross: For those that are trying for fertility, planning for fertility, I would get your partner involved. Advocate. If you're finding that you have a male partner that's not being involved in the whole process, make sure that we're actually testing. Advocate for them.

I think the groups in Utah are pretty good. All the female fertility groups are really good at making sure that things are getting tested. But if not, just ask.

Kirtly: Yeah, part of me says, "Oh, I want every 18-year-old to have a sperm count so they know well in advance what's coming down the pike." But that's a little silly, I know.

But I think helping men understand that if they do want children in the future, there are behaviors that will get in their way, and there are environments that aren't good for them. How do they maintain their options as they go forward? So that's a big one for me.

Any other tips for our ladies that are listening, but maybe guys too?

Dr. Gross: I think normalizing the process too, normalizing some of the stigma, making sure that we're talking about it sometimes. It's not just the female partner. There are two involved when we have a sperm and an egg, so . . .

Kirtly: Oh, good. Thank you. We'll finish up the way we started off. It takes a sperm and an egg.

Thank you, Kelli, very much for helping us think about it. And we'll go on to talk a little more about the environment in a little bit. Thanks so much, Kelli.

Our second part is on the geographic location, where you live, and how it affects your family planning and contraception choices. Of course, almost all advanced infertility clinics in the making baby part are in urban areas, and people who live far from an infertility clinic struggle with the labor-intensive and multiple visits of an infertility work-up, and certainly for an IVF cycle. But the geographic limitations of contraception options affect many more people.

So, Katie, can you talk about this, your role as a rural provider and educator?

Katie: Oh, man, can I. This was just driven home really viscerally to me recently. I think it's important to distinguish between urban and rural and frontier. Rural is one thing. You might be 30 or 60 minutes from a clinic. But frontier is something else entirely. In Utah, we have communities where the nearest provider offering a long-acting contraception or infertility treatment is a four-, five-, six-hour drive.

So I just did a Nexplanon training for a group of nurse practitioners in southern Utah. That was why I was so viscerally reminded of it. The day that I did that training. I left mid-morning and I had to pull over somewhere where I could find internet to take a meeting. And then I finished the drive and I got down there in time to do my training at the end of the business day. But at that point, it was a full day, and I did not have the energy or the stamina to drive back home. So in addition to doing this, I ended up having a night in a hotel to just get a good night's sleep so I could turn around and drive back home.

I was thinking about that in the opposite, that if I was the person coming to Salt Lake City for an appointment, that's a 24-hour commitment to sort of fit in the things that you need to do. You could say, "It's four hours away," but that's a hard drive to do back and forth in a single day, especially in the winter if the roads are slippery and it's dark outside, and you're really fatigued after that.

So I think that's one of the things that is . . . It's just hard to understand if you're not really living that. The places that seem relatively close, it takes a lot to get there. And then even if you do live close to Salt Lake City, Summit County, it still can be a contraceptive desert.

Kirtly: I like that.

Katie: I mean, I think that's one of the things that gets overlooked, is even places that seem relatively close to an urban center can still be a contraceptive desert. So if you don't have insurance, or you don't have reliable transportation, or if you're working hourly and you don't have time off, you might be 30 minutes from Salt Lake City but still not really have realistic access to care. So maps don't even capture the actual barriers that people face.

This is, again, a thing that I know about because I've been working with colleagues at the College of Nursing, and we've worked for a long time on grants that are focused on training nurses and pharmacists to work at what we call the top of their license.

That is, for nurses, we might be teaching RNs to provide well-woman-focused cancer screening visits, doing breast exams and Pap smears, services that are traditionally provided by a nurse practitioner or a doctor. But when there's not one in the community, you train sort of the next level of skilled provider to do those things to expand care.

And there are a lot of other initiatives where we have pharmacists dispensing contraception, understanding orders, and now we have the progestin-only pill available over the counter. So doing a lot of things to remove some of those barriers so that people have access to contraception.

I know we're going to get into all of this with our guest, and so I am excited to introduce in the virtual Scope studio, Dr. David Turok. Dr. Turok is board certified in OB/GYN and has a Master's in Public Health. He's a professor at the University of Utah. He's the director of the ASCENT Center for Sexual and Reproductive Health. He's actually internationally known for his work, reaching out to communities with limited family planning options.

Katie: Kirtly, I know you've been one of Dave's mentors, and Dave has been one of my mentors. In some ways, I owe a lot of my early research to the two of you, so this is exciting for me. Really special to get to have Dave on.

Kirtly: Yeah, you are both bright stars in my universe. Welcome, David.

Dr. Turok: Pleasure to be here. I am a long-time appreciator of this podcast, and side note, I frequently tune in when the world is rattling me a little bit for the soothing comfort that both of your voices provide.

Kirtly: Thanks, David.

Dr. Turok: It's always a pleasure. I just feel like, "Oh, I'm getting this opportunity to just sit and have a conversation with the two of you where I just listen."

Katie: We are so grateful for the work that you do. We had Jess Sanders on the social domain of family planning and she talked to us a bit about the ASCENT Center. But the ASCENT Center has been your brainchild. I've watched this develop from an idea and a group of people with a journal club to talk about. So I would love for you to tell us a little bit about the ASCENT Center from your perspective.

Dr. Turok: As you both know, because you've known me for so long, I had a strong commitment to the idea of expanding family planning services in Utah and the Mountain West. And I just started doing it.

And not through some incredibly strategic, precise, engineer-designed approach, but through natural evolution and organic growth, we now have a 25-person team that is expanding reproductive health rights and justice in Utah and the Mountain West. That includes clinicians, educators, administrators, working on all aspects of making sure that people can get the care they need, where they arrive, in a way that they want it.

As a clinician, when I walk into the room now, the first thing I always say is, "Hi, my name's Dave Turok, I'm the doctor. My job, everybody's job here is to make sure that you get the best medical care, and when you walk out of here, you feel respected." That sentiment and that approach informs basically all we do at the ASCENT Center. It's the best care as people define it, delivered with compassion that is affordable, and ideally no cost.

Katie: Yeah. Amazing. The research that you've done and just the innovation that you've brought to the field is really just amazing. So thank you for everything that you do.

Kirtly: And also, our thanks go out to those providers, physicians, nurses, nurse practitioners out in the rural and frontier areas who are aware of what I call the rubbers meet the road. This is where it happens, and this is where hard decisions are made, and people have to decide if they have to travel for four hours or can they get what they need. And so I'm really grateful for everybody who's out there.

Dr. Turok: Yeah, being a rural healthcare provider is super challenging. The demands and the resources that are available to put into play to meet these enormous demands are not adequate, and it takes some really special humans to provide that kind of care.

Katie: In your experience, what kinds of things are unique for the rural communities in terms of family planning?

Dr. Turok: The thing that the rural sites need isn't necessarily different than what the urban sites need. They need the training to provide the services, and they need it in a way that understands and meets their needs.

Fortunately for us, contraceptive care is not super complicated. This is very basic. Helping people have access to the methods that they can use to control their fertility to decide if and when they will have a pregnancy most of the time is really straightforward. It can get complicated in certain situations where people have medical complexities, but the vast majority of this stuff delivered with respect and compassion can go a very long way toward people's health.

The rural clinics needed, in lots of cases, ways to help people overcome the financial access barriers, and they needed training on things like learning how to put Nexplanon, the contraceptive implant, in and IUDs.

And one of the challenges in being a rural health provider is, in any healthcare setting, the more you do it, the better you get at it. Rural providers, especially because they have to cover such a broad scope of medical care, might get less exposure. Even family physicians and family health nurse practitioners, the actual number of contraceptive visits relative to all the other things that they have to take care of can be relatively few. And that creates, I think, some complexity. So appreciating where people are, I think, goes a long way.

Katie: You talked about this a second ago. You provided people contraception at no cost. If we take the cost barrier away . . . The travel is one thing, the trained provider is another, but there's also the cost to the patient.

Dr. Turok: So thankfully here on our team, we're very committed from the onset of the idea that yes, we're going to provide any method to anyone at any time, and if people want to come in and have their IUD or implant removed or switch from a pill to a ring or to an IUD, then we will support that. And they can switch as many times as they want over time.

Rebecca Simmons, one of my PhD colleagues on the ASCENT team, has done a whole bunch of research, and there's an amazing graphic on this that has a circle of all of the methods and essentially widened colored arrows that go from one to another to show which method people started with and where they went. And the mix really creates this pretty fabulous-looking web. The take-home is people switch and discontinue all the time, an average once per year.

Kirtly: And if they don't have someone who's agile, a provider who's agile, then that switching is the time that an unplanned pregnancy happens. So you need to have people . . .

When someone's unhappy because their bleeding is more than they want on one method and they want to come in today and switch their method, and you say, "Well you can come in two weeks." In the meantime, someone has stopped their method, and then when they come in, they're already pregnant.

Humans do switch around, or they don't like this or they do like that, and if you don't keep something on board while you're switching, lo and behold what you have is a baby on board. And that can be welcome or it can be very not welcome.

Dr. Turok: Right. As I know is fully appreciated by the three of us having this conversation right now, fertility returns to normal essentially as soon as you stop using any contraceptive method, except Depo-Provera, the injectable. But it goes back to normal right away.

And I think lots of people were like, "Oh, no. I was on the birth control pill for so long. If I stop, there's going to be some period of time that my body needs to get back to its normal cycle." No, it doesn't. Once the medication is not around, if you weren't ovulating before, it's coming back.

Katie: Yeah. A word to pill users, the reason you have a period at the end of a pill pack is you are completely out of pill. It's not working, and that's what triggers your period.

Dr. Turok: Yeah. So I think those transitions are critical.

And back to sort of the patient encounters, one of the things I always say when I'm providing somebody a new method is, "Hey, listen, this is good for as long as you want it to be, and this is not a lifelong commitment. If it doesn't work, come on back, and we'll help you get the next thing that works."

Katie: Right. I tell people that all the time. It's not a tattoo.

Dr. Turok: I like that.

Katie: You can change your mind.

Kirtly: So while we're talking about things moving, I'm going to take a tack a little bit and talk about male contraception. I'm hoping that we'll have something that works for guys, because I think in terms of geographic location, if you're located on the wrong side of the X chromosome, you don't really have that many options in terms of your contraceptive methods.

Dr. Turok: I'll cut to the chase. What's going to happen is the next generation is going to have better options than we've got now. For many decades before I was a medical provider, the male options haven't really changed. There are condoms, which are great. It's a thing you can use immediately, and obviously doesn't have systemic impact on your body.

Kirtly: It just takes up a tiny little space in your back pocket, which can actually be advertised if you wear it there all the time.

Dr. Turok: Yes. And vasectomy, which comes with no advertising and is amazingly effective and permanent pretty much, though it can be reversed, but if you're thinking about reversal, it's not the right method. And withdrawal, which is its own collection of issues and partner and trust and some related issues.

So condoms, vasectomy, withdrawal have been essentially the male methods for many decades. And it seems like there's some really great opportunity here based on the fact that sperm have some unique molecular components. There are proteins that exist on the surface of sperm and make sperm move and penetrate an egg that are not existent anywhere else in the body. That provides a whole bunch of targets. If you can make one of those components not work, then you've got an effective male contraceptive.

And we know for a lot of those very specific components that are involved in sperm maturation or sperm movement, penetration, or capacitation, which is the waking up of sperm in the fallopian tube so they can fertilize an egg, many of these very specific proteins, there are totally healthy male humans walking around who are infertile, who have lapses or imperfections in the genome in those places.

There are known targets, and there are a whole bunch of very smart, hardworking people who are working on a bunch of these things.

Let me talk about something, a study that's been done, completed, and you will be hearing more about, but there's a male contraceptive gel. We were one of the clinical sites for this, and for couples how to enroll in this study.

All of the couples that I talked to before they enrolled had the same story. "She's tried everything, now it's my turn."

The gel is hormonal. It works basically the same way that the birth control pill works or the vaginal ring. There's a hormone that's circulating, goes to the hypothalamus, prevents messaging to the pituitary to say essentially . . . Instead of like the birth control pill, which says, "Don't make a follicle and don't release an egg," the message is, "Don't make sperm and don't make testosterone."

So the gel has norethisterone. It's a progestin that essentially blocks that messaging. And since it also blocks production of testosterone, you've got to add back testosterone in the gel. So the gel has two components, norethisterone and testosterone. People use this. It's a "squirt one, squirt the other." Do that once a day, and it can provide highly effective contraception.

We're going to hear more about that. The work of the Phase II trial has been completed.

Katie: That is so exciting. And I want to add something about the information environment because I think it's going to be relevant as we get male methods. I'm already seeing it on social media. Certainly, we see it in women's contraception. There's a lot of content targeting reproductive-age women that's telling them that their hormonal methods are doing all these bad things to them. And I'm seeing similar targets towards males, that these male methods are going to cause problems for them or give them blue balls or other myths like this.

And so I think that that's something we have to be aware of as well. Whatever these influences are on social media that want to discourage the use of contraceptive methods, they're coming for males as well now.

And I always just want to point that out, that this is an agenda by people with a particular mindset, and they're using a lot of scare tactics, currently really directed at women, but I think that they're coming for guys too now.

Dr. Turok: There are clearly other opportunities, and we've got to do a better job with messaging what the benefits of contraception are. I am a firm believer that the demand for new male methods, regardless of gender, is there. I love for things to be really straightforward and simple, and it turns out that it's not that simple, which is why after a couple of decades of research, we still don't have a male method. But we are definitely closer than we've ever been, and there are more new and interesting products.

Kirtly: Well, as I think about how people are going to get good information . . . And I'm going to go back to when we finally do have better methods for men. A trusted source is still bedsider.org. If there's a method that's approved, it will give you really good information about it, true information, scientific information that's fun.

But also, if you are in a rural area and you don't know your local provider who actually knows about new methods or even older methods that are technical, you can put in your zip code, and they will give you a list of who might be closest to you.

So there's information out there about new methods that are coming on and about where you can find them.

However you might think about your family planning path, your environment is in your bedroom. Where you live, the air you breathe, your home environment, and your own body are making choices for you. Knowing how your environment affects your choices is important.

So if you're thinking about planning a baby, getting back to the family planning part, do the best to clean up your personal home and your neighborhood environment for the sake of your own fertility and for the sake of the baby you're going to grow.

All the reproductive toxins in our environment can be passed down to our child that you're hoping to carry. So if you're thinking about planning a family, planning a baby, think about cleaning up your own environment.

And if you're not planning on having a baby right now or ever, there are resources like bedsider.org to help you know what's available for contraception and where you can get it.

If you're a listener beyond your family planning years, we hope this series is giving you some things to talk about with your family and friends. Share some information and spark a conversation.

I want to thank Dr. Turok for joining Katie and me. Thanks, David, for bringing us up to steam on new stuff and some old stuff. Thank you very much.

And thanks for everybody who's listening. If this is the first of the 7 Domains of Family Planning that you're listening to, check out the other six domains and all of our "7 Domains of Women's Health" podcasts wherever you get your podcasts.

Stay healthy, stay well, and have the babies that you want.