Vaccination and fertility concerns
“For a while I thought less of myself as a person and as a man. I felt it was nature’s way of telling me there is something wrong with me and that’s why I am not able to have kids.”
“It’s in our DNA to make babies. That’s the purpose of sex when you are older is to make babies. It made me feel worthless that I couldn’t have kids.”
“It made me feel less of a man at the time knowing I may never father a child.”
This is how three men describe their experiences of infertility. It`s a difficult experience for anyone; especially when one factors in stigma,as well as the fact that it takes “time and considerable emotional energy to manage such feelings of loss.” It's not necessarily that being diagnosed with infertility changes one biologically. It changes one`s perception of themself, as is clear from the men`s statements above. Also, it is important to consider that fertility remains a taboo subject to discuss. Although there is increasing dialogue around the subject; it is not something one hears discussed in everyday conversations. Of course, this doesn't apply in all communities; but many.
As should be clear from the quotes above; having children is a major life goal for many people across the globe. Across various sources; the average number of children each woman in a developing country is 2.6 children. In Europe, each woman gives birth to an average of 1.6 children. However, this average conceals considerable variations from one country to another. Women in Spain, who have 1.26 children, are among the least fertile in Europe, while women in France, with 1.84 children, are at the top end of the spectrum. Niger in Africa has the world's highest birth rate. On average, each woman here will have 7 children, and Niger could see its population of 22.2 million almost triple to 63.1 million by 2030.
In China, there were 9.02 million births in 2023; with a fertility rate of just 1 child per woman. Further, according to the United Nations;in mid-November 2022 the eight billionth person was born.
It can therefore be said that many people invest significant time, energy, money, and other resources into birthing and raising children. For example, raising one child to 18 in the UK now costs in excess of £200,000 for single parents, and £150,000 for couples. In fact, in 2021, the cost of bringing up a child stood at £194,000 for a single parent. A large contributor to this is the cost of childcare services; which can account for 60% of the total cost of raising a child. In the U.S, the average cost of childcare can exceed $8,600 per year; regardless of whether it is centre-based or family child care. The key point here is that many invest huge time and money into children for years or even decades.
As a result, anything that is perceived to compromise can cause significant emotional distress. That is where hesitancy about vaccines comes in. Perhaps a couple struggled with fertility, or had one or several miscarriages. Perhaps they also had the high costs of raising a child when they did finally conceive. Maybe this happened on multiple occasions. They may also not have a background in the relevant area (and, in some cases, even people with medical/scientific backgrounds experience hesitancy). In any of these scenarios; any rumours about vaccines causing fertility issues could prime them to be hesitant about said vaccines.
Let's take another example. Maybe a young woman is pregnant with her first child. She may be unsure exactly what to expect or where to turn to for advice. For a myriad of reasons; she may not want to or may not be able to speak to a healthcare provider. So, she goes on the Internet. As we all do. As I discussed previously; there is an overwhelming amount of information to navigate online. Not to mention distinguishing fact from fiction. Therefore, many people are left without the tools to navigate the internet. As such, any headlines or articles calling into question how vaccines affect fertility can cause stress. This is regardless of whether they are true or not.
This gives some context for why some people may entertain the idea that vaccines impact fertility. It may be much more linked to their experiences than to the vaccines themselves. It is also crucial to note that fertility concerns often form part of a framework of issues for many people. Knowing that; let's examine some case studies where vaccines were believed to diminish fertility
For context; in 1988 the World Health Assembly launched a campaign to eradicate polio by 2000. The Global Polio Eradication Initiative (GPEI) is a joint effort between the World Health Organization (WHO), United Nations Children's Fund (UNICEF), Rotary International, US Centres for Disease Control (CDC) and national governments. According to the website of the WHO`s African office, the initiative required mass vaccination of every child. According to estimates, approximately 350,000 children were paralyzed by poliomyelitis globally each year. Thus; aggressive action was needed. In my view, the campaign name (Kick Polio Out of Africa) reflected this very well. Consider the name - “Kick Polio out of Africa.” Not “eradicate” polio, not “address” polio, but “kick” polio out.
With such intense efforts, it won't be surprising that significant progress has been achieved in polio eradication in Africa over the past several decades. Despite this, rumours about the oral polio vaccines (OPV) circulated and One of the most well-documented cases came from northern Nigeria in 2003. The political and religious leaders of Kano, Zamfara, and Kaduna states brought the immunisation campaign to a halt by calling on parents not to allow their children to be immunised. These leaders argued that the vaccine could be contaminated with antifertility agents (estradiol hormone), HIV, and cancerous agents. There were suspicions that the vaccine was part of a plot to sterilise Muslim girls; who make up the majority of the Northern Nigerian population.
Further, rumours circulated on social media that individuals in army uniforms were injecting primary and secondary school children with unknown diseases in an effort to eradicate the region's population. This caused mass unrest, panic, and even school closures in the South and North east. Parents also rushed to schools to take their children home. Not only this; several high-profile individuals gave credibility to such rumours, spreading and championing them. According to an article from theconversation.com; the boycott lasted for almost 15 months; from February 2003 to July 2004.
Unsurprisingly, this had significant implications for the polio eradication efforts in Nigeria. Despite Nigerian authorities efforts to dismiss the rumours, mistrust had already taken hold. By 2006; Nigeria accounted for 86% of polio cases on the African continent. Since then, the country has struggled to be polio-free. Further, the boycott may have transmitted the virus to surrounding countries. Strains of the virus that originated in Nigeria have been found in Yemen and Indonesia; which had already eliminated the disease. Not only this Nigeria remains the only country in Africa and one of the remaining three countries in the world that is not polio free. It may also impact future immunisation efforts. This may not only apply to future polio vaccination campaigns but many or all routine immunisations. As I've stated; if a population feels repeatedly mistreated, mistrust will grow. It will take significant time, multifaceted efforts, and funds to restore trust in vaccination in Nigeria to pre-boycott levels.
The HPV vaccine
One cannot address vaccination and fertility concerns without mentioning Human Papillomavirus (HPV) vaccination. According to the website of the World Health Organisation, concerns have been raised about the potential of the HPV vaccination to cause infertility; particularly primary ovarian insufficiency (POS).
A 2021 study published in the journal Reproductive Health aimed to explore these reproductive concerns of HPV - positive women. That is, women infected with HPV. The study found that participants worried about reduced fertility in both males and females, the impact of HPV vaccination on the health of the foetus, potential negative outcomes on the pregnancy (ie. miscarriage and preterm delivery), and the safety of vaccination while breastfeeding. In 2022, a study was published in relation to Colombian women's hesitancy towards HPV vaccination. In this case, lack of information regarding vaccination programmes, lack of awareness about vaccine benefits, concerns about vaccine safety and side effects, and the perceived relationship between HPV vaccination and promiscuity were all elements that contributed to hesitancy in this cohort of women.
It is also interesting to note that despite the majority of participants trusting the information itself and the healthcare system providing it, the concerns remain. For these reasons; context-specific factors are very key to think about. This is apparent when one reviews comments from study participants, including;
“I never had the power to decide if I wanted to get vaccinated or not; it was not a subject that I could get into”.
Others had anxiety about breaching the subject of sexuality with their daughters;
“I consider that in the subject of the infection with the human papillomavirus, it is possible to take a look from the biological point of view as the subject of the disease; let’s say that it is detached from the subject of sexuality and that is perfectly well because one can approach the subject with one’s daughter like that”.
Concerns about the vaccine causing promiscuity were also observed as contributing to hesitancy;
“I have an acquaintance who had this cancer because she began her sexual life very young. That person passed away.”
From these comments; it is clear that when talking to hesitant individuals it is important to ask questions tailored to them. What is it about their specific circumstances that makes them concerned about vaccination? Have they had difficult past experiences? Maybe someone they care about has had difficult past experiences. Why does it worry them? This allows effective communication and tailored solutions to be developed for each patient.
The final vaccinations that have had controversy around their possible impacts on fertility are the COVID-19 vaccines. For example, a 2022 study on infertile patients seeking fertility treatment showed “high prevalence of hesitancy in COVID-19 vaccines, and low coverage rate of the primary vaccination among couples seeking fertility treatment.” In the case of these participants; concerns include clinical characteristics of infertility; ongoing IVF treatment, concerns about vaccine safety and effectiveness, the possible influence of the vaccine on pregnancy, and the delay of the primary vaccination. Interestingly, COVID 19 vaccine hesitancy was correlated with longer periods of fertility treatment suspension.
What struck me about this study was although there was overlap among the concerns of infertile patients about COVID 19 vaccination and concerns of the general population, such as safety and effectiveness. However, they had concerns specific to their own fertility treatment, and any pregnancy that may result. For this reason, it is crucial to research these concerns and develop resources tailored to the concerns of patients undergoing fertility treatment. For example; further research on the possible impacts of COVID 19 vaccination on fertility treatments may be an avenue to research. The interaction of the vaccine with pregnancies resulting from fertility treatment could also be researched.
Most crucially, the authors said that “to the best of our knowledge, this was the first study to investigate the COVID-19 vaccine coverage rate, prevalence of hesitancy, and associated factors among infertile couples seeking fertility treatment” Therefore, it is clear that further research is needed in the area of what concerns infertile couples have around COVID 19 vaccination. Medical and scientific authorities could also engage these people to define what the most prevalent concerns are about COVID 19 vaccination, and the areas research is most needed around.
I`d add that research should be done on their concerns around vaccination in general, outside of just COVID 19 vaccination. There may be more concerns about one vaccine than another. Patients may also have had more negative experiences with one disease or vaccine than others. This will help establish if one vaccine or one concern needs prioritising in the research. It would also help to monitor common rumours and concerns circulating within this population; and also how they change over time. Such efforts could make such patients feel that their concerns are being heard by the scientific community. This in turn could begin to build trust between the scientific and medical community and this group of patients. Future vaccination efforts may hugely benefit from this, as a base of trust and open communication would already be established.
To summarise; people's circumstances can vary to a huge degree. For this reason, people often hold very diverse reasons for believing fertility myths about various vaccinations. This can lead to them hesitating about or rejecting one or more vaccines. Having individualised discussions can help achieve more effective solutions and therefore save more lives. It is also crucial to work on building trust in a tailored way with each subgroup of vaccine hesitant individuals. This will benefit not only current vaccination efforts, but future ones. Trust is a feature of long-term friendships or relationships. In other words, it needs to be actively worked on all the time. That is the way we need to consider trust between vaccine hesitant groups and health authorities. This is especially true when we`re discussing fertility concerns. The reason for this is that fertility is an aspect of healthcare where patients are more vulnerable in comparison to other areas of medicine. Thanks for reading!