Environmental Health
Toxic Matters and Fertility What Can a Doctor Do? Patrice Sutton, MPH; Tracey J. Woodruff, PhD; Jeanne A. Conry, MD, PhD; Linda C. Giudice, MD, PhD, MSc About eight years ago, an infertility patient asked her physician whether her exposure to environmental chemicals as a child growing up near a chemi-
cal waste site was a factor in her inability to conceive a child. The patient’s inquiry was a wake-up call for her physician, who knew that scientific barometers of reproductive function among the U.S. population (ranging from reduced sperm counts through difficulty in conceiving and maintaining pregnancy) and increasing rates of various reproductive illnesses point to declines in our reproductive capacity.1 Her physician also knew these adverse trends in reproductive health have occurred in roughly the same time frame in which human exposure to both natural and synthetic chemicals has dramatically increased.2 Today, virtually all pregnant women in the U.S. have measurable levels of multiple environmental chemicals in their bodies that can be harmful to human reproduction and/or development.3 A rapidly expanding body of scientific evidence has upended assumptions about the benign nature of such “low-level” environmental exposures.4,5 This is because the human reproductive system is particularly vulnerable to ambient levels of environmental chemicals when these exposures occur during “critical or sensitive windows of development,” i.e., in utero and during infancy, childhood, and adolescence.6-8 Preconception and prenatal exposure to environmental chemicals may have a profound and lasting impact on health across an individual’s entire lifetime.9
What Can a Doctor Do?
In light of the growing scientific evidence about the health impacts of developmental exposure to environmental toxics, the aforementioned patient’s question also sparked her doctor’s recognition that reproductive health professionals are uniquely poised to intervene in critical stages of human development to prevent harm. However, while taking steps to prevent preconception and prenatal exposure to toxic substances can have a lifetime of health benefits, there were many barriers to incorporating this new information into clinical practice. Nascent efforts to seize the largely untapped opportunity to engage reproductive health professionals in prevention efforts began by drawing on the experience of the pediatric community, which has long recognized the impact of the environment on children’s health and has responded by developing prevention-based clinical guidelines1 and professional policies.10,11 Over the last decade, the Collaborative on Health and the Environment (CHE) and partners have figured prominently in advancing these efforts. 20 San 21 SanFrancisco FranciscoMedicine Medicine June June2012 2012
How Health Professionals Are Responding Selected highlights of milestones in crafting an evidencebased response by health professionals to the science linking the environment to reproductive and developmental health include: • 2005 Vallombrosa Consensus Statement on Environmental Contaminants and Human Fertility Compromise. CHE was a coorganizer of a meeting that brought together, for the first time, researchers in reproductive epidemiology, biology, toxicology, and clinical medicine; representatives of professional societies; and infertility support and women’s health and reproductive advocacy organizations to review the state of environmental health science as it pertains to infertility. Meeting participants issued and disseminated a consensus statement to help scientists, medical professionals, and public health advocates understand, with a broad brush, the current state of scientific understanding in the field and to identify important research areas that will be crucial to further advances.12 • 2007 Summit on Environmental Challenges to Reproductive Health and Fertility. Cosponsored by CHE and the University of California, San Francisco (UCSF) Department of Obstetrics, Gynecology, and Reproductive Sciences, the summit convened 400 community group members, clinicians, researchers, and policy makers from around the world and was allied with eighteen leading professional societies in the field of reproductive health.13 The summit led to a series of recommendations for advancing the field of environmental reproductive health, including agreement that the scientific evidence warrants the active engagement of reproductive health professionals in prevention. • 2007 Program on Reproductive Health and the Environment (PRHE). UCSF founded PRHE with the goal of creating a healthier environment for human reproduction and development through advancing scientific inquiry, clinical care, and health policies that prevent exposures to harmful chemicals in our environment. As exemplified in the resources developed for clinicians listed in Table 1, since its inception PRHE has tackled head-on the question, “What can a reproductive health professional do to prevent toxic environmental exposures?” Since many harmful environmental exposures (i.e., air and water pollution) cannot be prevented by individual action alone, engaging the influential voice of health professionals and their institutions and organizations in advancing environmental health policy has gone hand in hand with PRHE’s efforts to integrate the science into clinical practice. • 2009 From Advancing Science to Ensuring Prevention (FASTEP) Alliance. In collaboration with CHE and many www.sfms.org