October 31, 2013 — Summary of "Exposure to Toxic Environmental Agents," American College of Obstetricians and Gynecologists et al., Fertility and Sterility, October 2013.
Substantial evidence shows that human exposure to toxic environmental chemicals and other stressors is universal and that preconception and prenatal exposure to such agents can have serious, lasting effects on reproductive health, according to a committee opinion by the American College of Obstetricians and Gynecologists' Committee on Health Care for Underserved Women, the American Society for Reproductive Medicine Practice Committee and the University of California-San Francisco Program on Reproductive Health and the Environment.
More specifically, "[p]renatal exposure to certain chemicals has been documented to increase the risk of cancer in childhood; adult male exposure to pesticides is linked to altered semen quality, sterility, and prostate cancer; and postnatal exposure to some pesticides can interfere with all developmental stages of reproductive function in adult females, including puberty, menstruation and ovulation, fertility and fecundity, and menopause," the opinion states.
Notably, "vulnerable and underserved populations" are disproportionately exposed to toxic environmental agents, it continues. Because of these dangers, "reducing exposure to toxic environmental agents is a critical area of intervention for obstetricians, gynecologists, and other reproductive health care professionals," according to the opinion.
Reproductive Health and the Environment
Over the past 15 years, "[r]obust scientific evidence has emerged" demonstrating that preconception and prenatal exposure to toxic environmental agents can have serious, long-term effects on reproductive health, the opinion states.
Exposure to environmental agents such as chemicals and metals in air, water, soil, food and other consumer products is unavoidable and "can lead to harmful reproductive health outcomes," the opinion states. In pregnant women, chemicals can penetrate the placenta and accumulate in the fetus, leading to higher fetal exposure than maternal exposure and resulting in various adverse health outcomes.
Vulnerable Populations Disproportionately Exposed
"Recognition of environmental disparities is essential for developing and implementing successful and efficient strategies for prevention," the opinion states.
While all humans are exposed to environmental toxins, vulnerable and underserved populations often are disproportionately exposed to agents that are believed to be harmful to reproductive health, according to the opinion. In the U.S., minority groups often are more likely to live in areas with the highest level of outdoor air pollution, and they also are more likely to be exposed to indoor pollutants like lead, allergens and pesticides. Injustice, poverty, neighborhood and house quality, psychological stress, and nutritional status can exacerbate the negative effects of toxin exposure.
Women who work with toxic chemicals are highly vulnerable to adverse reproductive outcomes. Low-wage immigrant populations disproportionally work in occupations with hazardous work environments, the opinion notes.
Prevention and Preemptive Guidance
Because of the robust evidence linking toxic environmental agent exposure with adverse reproductive and developmental health outcomes, ACOG and ASRM "join numerous other health professional organizations in calling for timely action to identify and reduce exposure to toxic environmental agents while addressing the consequences of such exposure," the opinion continues. It adds that reproductive health care providers "are uniquely poised to intervene before and during pregnancy, which is a critical window of human development."
To start, health care providers should learn about toxic environmental agents in their geographic areas. Then, providers should intervene as early as possible during preconception to "alert patients regarding avoidance of toxic exposure and to ensure beneficial environmental exposure." Because exposure might have begun before the first prenatal visit, providers should gather a patient history to pinpoint any types of exposure that could harm a fetus, including those at both the maternal and paternal workplaces.
Once an exposure inventory is obtained, providers should give patients information about how to avoid toxic agents, as well as possible referrals to occupational medicine programs or the U.S. Pediatric Environmental Health Specialty Unit if serious exposure is detected. Information about avoiding toxic agents also can be disseminated through childbirth classes or written materials, the opinion suggest.
Providers also should educate their patients about steps they can take to reduce their exposure risk, such as switching to organic vegetables, avoiding canned foods and other dietary sources of bisphenol A, short-term dietary changes that reduce exposure to phthalates, and limiting intake of large fish. During preconception, patients should be encouraged to eat healthy foods and avoid fast food and other processed foods when possible.
In addition, providers must be sure to identify and report any hazards they discover. Local health agencies and the Association of Occupational and Environmental Clinics can provide resources on how to report hazards.
Reproductive Care Providers as Policy Advocates
According to the opinion, "individuals alone can do little about exposure to toxic environmental agents, such as from the air and water pollution, and exposure perpetuated by poverty." Thus, "[t]he incorporation of the authoritative voice of health care professionals in policy arenas is critical to translating emerging scientific findings into prevention-oriented action on a large scale," it states.
The opinion notes that "many medical associations have taken steps in that direction." AGOG and ASRM join these groups in "call[ing] on their members to advocate for policies to identify and reduce exposure to environmental toxic agents while addressing the consequences of such exposure."
Specifically, the opinion calls for pursuing a "primary prevention strategy" of advancing practices that support a healthy food system. In addition, it urges the "Environmental Protection Agency and other federal and state agencies to take all necessary actions when reviewing substances to guarantee health and safety."
In conclusion, the opinion urges more research on the link between toxic environmental agents and reproductive health but notes that "[b]ecause data are lacking on the safety of most chemicals, careful consideration of the risks posed must be given while the potential immediate and long-term health and genetic risks are evaluated. A chemical should never be released if a concern exists regarding its effect on health."