"We always joked about turning into the pink mist, just a big splatter of blood. We never talked about what to do if I couldn’t have kids.”
Four years ago in Afghanistan, US Army Sgt. First Class Aaron Causey was called to investigate a possible improvised explosive device hidden inside a culvert.
Causey was a part of the 760th Explosive Ordnance Disposal Company, a team dedicated to finding and disarming IEDs. The bomb he was checking out that day turned out to be a decoy—a "hoax device," soldiers called it—which meant the real ones were still nearby.
"I'm being set up," he recalled thinking, just before he stepped on the real bomb.
"Causey's in the air!" one of his company members screamed.
Two days later, he woke up in a hospital in Germany. He was missing his legs. One testicle was gone. One-third of the other testicle was gone. His penis remained intact, but his doctor said he would not be able to conceive naturally because most of the testicular tissue that produces sperm was blasted away.
"We always joked about turning into the pink mist, just a big splatter of blood. But you never really talk about what to do if you get injured," Causey said. "And we never talked about what to do if I couldn't have kids."
Of the 53,000 American forces injured in Iraq since 2001, more than 1,200 American troops have had genitourinary injuries. Most were due to IED blasts, according to data from the Department of Defense. Out of those troops, 37 percent had "severe" injuries involving damage to the testicles, rectal tissue, or penis. Many were left with fertility issues, leaving them to figure out how, or if, they could have children.
The military generally does not send people to war unprepared. Before deployment, service members are briefed on the stresses to family life, and partners back home are emotionally prepared for if their loved one dies in combat. However, at a recent conference for injured veterans, families said loss of fertility was never discussed—even though often the first question from a man after waking up from severe injuries is reportedly, "How's my junk?"
This lack of advance warning is even more devastating because the two most important windows for sperm banking are before deployment and immediately after injury. Without preparation, these windows can pass without the soldier getting the chance to preserve his chance for natural conception.
The more time passes after the injury, the less successful sperm banking may be. That's why the British Army has a procedure for genital injuries that can compromise fertility: If a soldier has a testicle blown off, doctors automatically will remove and preserve sperm from the damaged tissue to ensure the chance of having children. The US does not have a similar procedure in place to collect sperm when a soldier has a scrotal injury.
The first question from a man after waking up from severe injuries is reportedly, "How's my junk?"
Recently, however, some researchers have had success with growing testicular tissue in the lab. Eventually, this could lead to reconstructing working testes and transplanting them back onto soldiers.
Since 2013, the military has given $300 million in funding to research institutions that focus on facial and limb transplants, which also includes fertility research.
One of those institutions, Wake Forest Baptist Medical Center in North Carolina, has managed to use troops' own cells to reconstruct a brand new, working testicle—but for now, it's the size of a pinhead.
By using a few millimeters of damaged tissue, doctors can extract testicular stem cells which can then be used for growing a miniature testicle. It's almost microscopic, but the testicle has all the capabilities of producing sperm normally. Inside the organ, immature sperm cells are created with the help of testosterone, gather toward the center and then mature with the help of "nurse" cells that create functioning sperm.
"The future plans are to grow the testicular tissue, expand the cells and put it back into the patient," said Dr. Anthony Atala, director of the Wake Forest Institute for Regenerative Medicine. "But for a whole testicle, there is a very rich blood-vessel supply and that's the challenge. We can make them small, but we're working hard to make them larger."
This wouldn't be the first advance in fertility technology using testicular stem cells. For patients suffering from testicular cancer, doctors currently are able to take biopsies of testicles and freeze sperm-creating stem cells before chemotherapy, which ruins sperm production. After treatment, those stem cells are reintroduced back into the testicle and sperm creation continues.
This would be the first time, though, that doctors would use stem cells to create an entirely new and viable testicle which has the capability of conceiving a child without in vitro fertilization (IVF).
For years, troops have been able to get prosthetic testicles and go through IVF treatment if there is viable sperm to harvest. There is also the possibility of a testicular transplant from a donor, although these are extremely rare: there has been only one such reported testicular transplant conducted in the US, in which a man born without testicles received one from his twin brother.
Testicular transplants can introduce unique ethical issues, since unlike other organs, they reproduce. A donor would be essentially agreeing to pass on his genes to the recipient's children, which can be a heavy call to make. This is even fuzzier when it's the family making the decision on behalf of a donor. (Typically, donors have to give consent for doctors to take their internal organs, but there is no federal regulation covering reproductive organs, and many states leave it up to the surviving family to decide.)
If Atala's team can make the procedure for creating a whole new testicle from the stem cells of a patient efficient and affordable, it could give injured soldiers another chance at having kids. But for now, troops shouldn't expect to be getting new testicles anytime soon: the process of testing, trials and approval is still at least a decade away, Atala said.
In a policy memo issued by the Army's medical command in 2013, the Army noted that soldiers had "indicated a desire to have their [sperm] collected and stored" in the event of an injury and outlined all the ways active duty soldiers could bank or collect sperm. That memo is available to soldiers before deployment, said the Army.
If soldiers wanted to get their sperm banked beforehand, they would have to do so at their own expense, according to the policy. The policy memo expired June of last year but is currently under revision to include cancer patients undergoing treatment, said the Army.
The Army acknowledged that there were no ways to collect sperm during deployment, and said Congress needs to act if there are to be any changes to sperm collection after an injury.
In the meantime, the Army issues two different kinds of protective gear for troops' nether regions: a synthetic underwear made of silk and a Kevlar plate protecting the groin (soldiers call them "blast boxers" and "blast diapers"). But a study done last year by the University of Southern California found that a large number of soldiers don't wear their protective gear, and called for an investigation as to why.
"The biggest barriers to the protective gear are still making it comfortable to wear so that troops want to wear it and enforcing the use of protective equipment," said Dr. Sherrie L. Wilcox, an assistant professor at USC who authored the study. "There will always be a challenge between wearability and protection—the best protection will likely be bulky and less comfortable."
It's almost microscopic, but the testicle has all the capabilities of producing sperm normally
The study also made suggestions to alter the design of protective gear to help protect ovaries, especially now that women will become more widely used on the frontlines of the battlefield. Right now, the gear sits too low on the hips to protect anything above the groin area.
"The currently available equipment is really geared toward men," said Wilcox. "Unfortunately, there hasn't been much additional movement that has been publicly announced."
But despite any possible future changes in how the gear fits, some soldiers say it's useless against the force of an IED blast.
"This groin protector is essentially a flap that hangs down in front of your groin," said Causey, who was not wearing his blast boxers or blast diapers at the time of his injury. "It's really not going to do much in the case of a blast, it's more there for getting shot. I was more worried about getting blown up."
Despite not wearing all their gear, more troops are surviving IED blasts than in previous wars, primarily because of better medicine and technology. That means more veterans having to live with life-changing injuries.
Aaron Causey's story has a happy ending.
When he was unconscious and in recovery, his wife Kat gave doctors permission to extract sperm from one of his testicles. Unfortunately, the procedure did not produce any viable sperm.
"I just sat on the floor and cried," she said.
Aaron and Kat could have sex, but Aaron's doctor said the probability was very low that he would conceive naturally. So a year later, the couple had to make another decision. Aaron's retirement was coming up, and if they were to have child through artificial insemination, it needed to be then. The military pays the full cost for in vitro fertilization for married soldiers through Tricare, the health insurance offered for all active military personnel. Once someone leaves the military, however, they lose Tricare and become eligible for Veterans Affairs benefits, which do not cover IVF.
That's because in the 90s, Congress passed a ban on VA benefits covering IVF treatments. The move was backed by conservatives who were worried that fertilized frozen embryos would be destroyed. Abortions and abortion counseling services were also removed from VA benefits.
Sen. Patty Murray (D-Wash) introduced legislation this year to cover IVF treatments for injured veterans, but Senate Republicans blocked the bill in February. The legislation would have covered 1,800 veterans, majority of them with genital injuries, at a cost of $568 million over five years, according to the Congressional Budget Office. Republicans argued the cost to cover fertilization was too high.
The Causeys couldn't wait to see if Congress would act. If they didn't do the procedure before Aaron lost his Tricare insurance, they faced a bill of up to $6,000 for a single attempt at IVF. (That cost was even after Causey's veteran's discount at Walter Reed Medical Center. The same procedure would cost a civilian upwards of $15,000 per treatment.)
"We had to do it then, you know? I'm only getting older and my injuries are going to eventually limit my movement. I want to be able to play with my kid," Aaron said.
Aaron started his nine-month fertility treatment in preparation for IVF. He never finished it. To the couple's surprise, Kat got pregnant without having to visit the lab.
They named the baby, born January 27, 2014, Alexandra Jayne "A.J." Causey.
"We like to say she was two-thirds of a nut and a little luck," Kat said.