When Marine Lance Cpl. Mark Fidler stepped on an IED in Afghanistan in 2011, his mother, Stacy, was vaulted into the world of combat trauma recovery — of amputations, soft tissue injury and countless surgeries — as she supported her son during recuperation at Walter Reed National Military Medical Center, Bethesda, Maryland.
During that time, Stacy Fidler also became an advocate for several causes: for blood donations, since Mark required 188 units in the first 48 hours after his injury; and for an unconsidered need among troops with severe pelvic injuries — fertility preservation.
During a conference on combat-related infertility in late 2014, Stacy Fidler urged the U.S. military to publicize sperm banking during pre-deployment briefs and adopt medical policies to harvest sperm following a genitourinary injury, just as the United Kingdom does for its service members.
"This is difficult for a mother to speak about," Stacy Fidler said. "But these are young men who are not thinking about possibly losing the ability to have children."
Nearly 1,400 veterans of Iraq and Afghanistan experienced injuries to their pelvises and groins that make it difficult or nearly impossible to have children without medical assistance.
For some troops, existing fertility treatments, such as sperm harvesting and in-vitro fertilization, can help.
But for others who have lost function completely or no longer have their reproductive organs, academic institutions, including Wake Forest Baptist Medical Center in Winston-Salem, North Carolina, and Johns Hopkins Military and Veterans Health Institute in Baltimore, are stepping in to help.
Their goal is to advance research that could restore sex, fertility and quality of life to young men in the prime of their lives.
At Wake Forest, scientists are growing testicular tissue and penises in their laboratories and preparing to conduct penis transplants.
"Injuries in our young, wounded warriors have definitely made additional investments possible in the field of regenerative medicine and accelerated development of these technologies," said Dr. Anthony Atala, director at the Wake Forest Institute for Regenerative Medicine.
Among the projects gaining traction at Wake Forest is an initiative to grow testicles from testicular stem cells taken from injured patients. Atala and colleagues have grown microscopic testicles capable of producing testosterone and are working toward the next milestone: creating a working testicle that can produce sperm.
The idea, Atala said, is to be able to take a small piece of testicular tissue from a patient immediately after an injury, or even before a person is placed in harm's way, and use the tissue as a base to grow a new testicle if needed.
Atala said a sperm-producing testicle may still be a decade off, but it is a possibility, given that the Wake Forest facility has grown bladders, urethras, livers, kidneys and vaginas in its lab.
"The one nice thing about testicles is you need just one sperm. It only takes one sperm for the functionality to be realized," Atala said.
Wake Forest already has proved that growing a functional penis in a lab is possible, at least for animal models. In 2008, the team engineered 12 rabbit penises, which they then grafted onto male rabbits with an aim to breed them with a female. According to medical literature, all rabbits mated with the female, eight ejaculated and four produced offspring.
Atala admits that growing human penises is more of a challenge because they are larger and must last a human lifetime. Atala has engineered at least a half dozen in the lab and continues to test their viability. But the institute has received approval to conduct transplants on humans and is assessing potential patients, Atala added.
"We have the approvals in place and are ready to go," Atala said.
The Wake Forest program is part of a team supporting the Armed Forces Institute for Regenerative Medicine and has received more than $300 million since 2013 from the Defense Department to conduct research on tissue regeneration and injury reconstruction.
Most recently, it and other facilities involved in the Armed Forces Institute for Regenerative Medicine were awarded a $75 million contract to continue their work in the field of skin regeneration, limb function restoration, skull and facial reconstruction and transplants.
Johns Hopkins University School of Medicine is another major medical facility conducting cutting-edge research to help troops with devastating genitourinary injuries. At Johns Hopkins, doctors are preparing to conduct the first penis transplant procedure in the United States, using a donor penis.
The first penis transplant was attempted in China in 2005, but that operation failed and the organ was removed after a couple of weeks. In late 2014, a team at Tygerberg Hospital, Cape Town, South Africa, successfully transplanted a donor penis to a 21-year-old male who lost his organ following complications of a failed ritual circumcision.
Johns Hopkins officials hope this groundbreaking surgery will allow some service members to regain sexual function and father children. Earlier this month, they said the first candidate for such a transplant will be designated soon.
"The goal of penile transplant is to provide an advanced reconstructive option to patients with devastating penile injuries that will improve their function over standard techniques or who are not candidates for these techniques," explained Dr. Damon Cooney, a member of the Johns Hopkins team who addressed a symposium hosted by the Bob Woodruff Foundation in Washington, D.C., in December 2014.
While male service members make up the bulk of patients with combat-related genitourinary injuries and consequential fertility issues, researchers aren't ignoring the needs of women with pelvic injuries or defects.
The Wake Forest team has successfully transplanted vaginas grown from patients' own cells into women born with birth defects and engineered functional ovaries in their laboratories.
Still, the technology is a long way from helping injured troops who would like to have children now or within the next decade.
For most, advanced reproductive technologies such as sperm harvesting, in-vitro fertilization and intrauterine insemination are the only options available.
But while injured troops have access to fertility treatments when they are on active duty, they do not have medical coverage for such services as medical retirees or veterans, because Tricare, the health program for military retirees, and the Veterans Affairs Department, which is responsible for providing medical care for service-connected conditions, do not cover them.
Sen. Patty Murray, D-Wash., has introduced legislation several times since 2012 that would cover IVF and other fertility services, including surrogacy, for veterans. But the most recent iteration of Murray's bill was scuttled in 2015 after it became entangled in a debate over funding for Planned Parenthood.
Some lawmakers also have questioned the cost of the bill, which has been estimated to be $568 million over five years by the Congressional Budget Office.
But some veterans organizations, including Wounded Warrior Project, say the estimate is too high, because it assumes that all injured personnel would request the services. They also argue that as a service-connected condition, VA has an obligation to pay.
"These veterans and their spouses are left with a difficult decision — forego any hope of having children or pay tens of thousands out of pocket for the chance to start a family. We obviously owe them better," said Lauren Mehta, managing counsel at Wounded Warrior Project, which has made combat-related fertility treatments a top legislative priority this year.
While veterans groups press Congress to change the laws regarding fertility services for veterans, researchers at Wake Forest, Johns Hopkins and elsewhere continue to work toward solving the issues that cause infertility.
They believe they are on the cusp of several medical breakthroughs.
"When I started in regenerative medicine, it was like science fiction. Just the field of growing cells was a challenge. … The question now is not 'Can it be done?' But 'How do we capture the strategies we've learned from making other tissues apply to these?'" Atala said.