“Helping Military Families Grow”: Increasing Infertility Coverage for Active-duty Servicemembers and Veterans

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“Helping Military Families Grow”: Increasing Infertility Coverage for Active-duty Servicemembers and Veterans

Authors:

Callie J Hamai, Savannah D. Groves, Tea Kostandinis, Sofia Girald-Berlingeri, Kayle E. Simon, Alicia Y. Christy, MD, Albert L. Hsu, MD

University of Missouri School of Medicine

Abstract:

New Congressional legislation is periodically introduced to expand government-sponsored health plans, such as TRICARE, Veterans Affairs (VA), and the Federal Employee Health Benefits (FEHB) Program, to include coverage for infertility services, as well as fertility preservation in cases of cancer.1   To date, none of those bills have yet to be signed into law.  In this article, we review current guidelines and information regarding infertility coverage among active members of the military and veterans.  Given reports of rising fertility concerns among our military and veteran communities, we argue for broader infertility coverage for our veterans and active duty servicemembers.

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Introduction

The United States Centers for Disease Control and Prevention (CDC) estimates 1 in 8 couples in the US encounter challenges in conceiving or sustaining a pregnancy.2  In the past, female infertility was thought to be the primary cause of difficulty conceiving, and male fertility was frequently not considered to be a significant cause.  However in some studies, the male factor has shown to be solely responsible in about 20% of couples with infertility while being a contributing factor in an additional 30-40% of couples.20  3   For some couples struggling with conception, in vitro fertilization (IVF) is sometimes the only viable option to conceive biological children. 

Despite many infertility cases among active-duty servicemembers, eligibility criteria for IVF and cryopreservation in the military and veterans are narrow and exclude critical services, such as the use of donor sperm, donor eggs, donor embryos, or gestational carriers.5  Furthermore, to qualify for coverage, the cause of infertility must be directly service-related, and beneficiaries must be legally married.  Such criteria exclude many veterans and active duty servicemembers from accessing coverage for infertility care.  While certain programs, such as the Bob Woodruff Veteran In Vitro Initiative, can help eligible active duty servicemembers and veterans overcome a select few of these limitations, expansion of government-sponsored health plans should be considered as a pro-military and pro-family measure that supports family-building among military members.  To promote fairness, infertility services should be provided to all active duty members and veterans rather than to a select few.

 Given limited resources, concerns have been voiced regarding the costs of expanding fertility coverage.  Currently, 19 states have passed laws requiring insurance coverage for certain fertility services, and 13 of those states specifically mandate IVF coverage.6 Interestingly, many states that cover IVF treatment have found expanded coverage to be more cost-effective in the long term.7  In this article, we aim to describe the concern for infertility amongst active-duty servicemembers and veterans and the insurance options available to them as well as explore some of the unique factors that impact fertility in this population.

Infertility Rates & Current Military Coverage

In 2019, the Department of Defense (DOD) reported that among active female servicemembers, the incidence of infertility diagnosis was 63.8 per 10,000 with an overall prevalence of 142.3 per 10,000.8  Comparing military branches, the Army has the highest incidence rate (101.7 per 10,000) of female infertility diagnoses, while the Marine Corps has the lowest (50.4 per 10,000).8  The DOD defines infertility as “having at least 2 outpatient medical encounters with an infertility diagnosis,” which is likely why these rates of infertility are approximately 10-15x lower than that of the general population.”Despite these statistics and declining birth rates in the US,10 infertility coverage for servicemembers and veterans remains quite restricted.  Currently, there is no standard infertility coverage for active-duty military servicemembers.5  The current coverage for in vitro fertilization (IVF) is limited to those who suffered a service-related injury or illness that resulted in infertility. For example, a male patient who sustained a spinal cord injury after an Improvised Explosive Device (IED) detonation and can no longer ejaculate would have IVF coverage if he and his partner are legally married and do not require donor gametes. In contrast, present coverage fails to provide options for families without easily identifiable, service-connected conditions resulting in infertility and does not provide services for non-veteran partners or servicemembers not legally married to their partners.  Of note, active-duty military personnel and their dependents that meet these qualifications have limited coverage for infertility care and oocyte cryopreservation services at seven specific Military Treatment Facilities:  Walter Reed National Military Medical Center/Bethesda Naval Hospital in Bethesda, MD; Womack Army Medical Center at Fort Bragg in Fayetteville, NC; Wright-Patterson Air Force Base near Dayton, Ohio; San Antonio Military Medical Center in San Antonio, TX; San Diego Naval Medical Center in San Diego, CA; Tripler Army Medical Center in Honolulu HI, and Madigan Army Medical Center in Seattle-Tacoma WA.  However, not every interested active-duty military member and their spouse is able to travel to these locations, leaving them unable to benefit from services they qualify for under TRICARE policy.  Even after all qualifications are met and allowing that individuals are able to travel to one of the listed places, the DOD does not provide coverage for many infertility services for most with military insurance, including artificial (intrauterine) inseminations, costs related to sperm or oocyte donation, sterilization reversal, psychogenic erectile dysfunction, or in vitro fertilization. Additionally, sterilization reversal and psychogenic erectile dysfunction treatment is available at some but not all centers.8 Finally, there are no VA facilities that offer in vitro fertilization (IVF) services. 

Unique Military Challenges

Compared to the general population, military families face unique challenges that can complicate family building and planning.  During military service, active duty servicemembers may experience exposures to potential chemical, physical, and environmental hazards such as jet fuel, burn pits, spent uranium, nuclear power plants, and exposures associated with submarines and aviation, all of which may be linked to negative effects on reproductive health.11  Exposure to endocrine-disrupting chemical agents including lead, mercury, or certain pesticides is shown to result in altered semen quality and sterility in men as well menstrual cycle interference in women.21, 22   A clear, causal link between military environmental exposures and infertility has yet to be established.12 However, several studies demonstrate an association between military service and Post Traumatic Stress Disorder, depression, toxic exposures, and their negative impact on fertility.3, 12  It is vital to acknowledge that infertility is multifactorial, and it is hard to prove a direct cause in many cases, especially among female veterans.3  This makes it virtually impossible to cover IVF under current legislation for cases with no obvious service-connected cause for their infertility.

Currently, cryopreservation coverage is limited to documented medical indications for fertility preservation, such as prior to chemotherapy. It fails to account for fertility preservation in active duty servicemembers and veterans with past exposures to sometimes-unknown toxins and physical or emotional stressors while in the service.  Increased monitoring in active duty servicemembers for exposures or stressors should be established to increase reporting of infertility-associated factors. It is also important to provide timely reproductive support to those attempting conception and to those who enter the military before having the opportunity to conceive biological children. Active duty servicemembers and veterans who delay their attempts at conception as a result of their service, should have an opportunity to cryopreserve their gametes similar to individuals in the private sector.  As several large private companies now offer oocyte cryopreservation benefits to their female employees, initiatives to offer oocyte or sperm cryopreservation to servicemembers prior to deployment should also be supported.

As a result of the increased number of women in the military, female veterans of reproductive age are the fastest growing segment of the veteran population in the US4.  Active-duty servicewomen relocated to severe environments can have limited access to medical services and as a result, women often experience interruptions in preventative health care services, such as cervical cancer screenings, and are at increased risk of urinary tract infections or bacterial vaginosis.13  In addition, military service can also delay workup or treatment of conditions like abnormal uterine bleeding and endometriosis, which may potentially increase the risk of infertility.3,13

Many veterans and active-duty servicemembers spend their reproductive years in service and frequent change in geographic locations further complicates reproductive planning and timing.  The possible resultant delay in conception contributes to the largest risk factor for both partners – age.14, 23 Current benefits do not provide adequate support for male or female veterans who chose to delay pregnancy to serve their country.  Furthermore, current benefits also exclude non-veteran partners who delay pregnancy while awaiting their partner's return from deployment. In 2018, a Research and Development Corporation (RADC) report on Air Force female officers’ retention found that the lack of work-life balance, particularly in relation to growing their families, negatively impacted their desire to remain in service.

Cost-Effectiveness

In states that do not cover IVF treatment, the high initial cost of IVF leads to the practice of riskier and less effective options, such as deviations from national recommendations for the number of embryos transferred by individual patients, increasing the risk for premature and multiple births.15 Consequently, states that do not provide IVF coverage have the highest rates of multiple gestation, especially triplets or more.16 These events can lead to higher costs in post-natal and long-term care, as well as incurring increased risks to maternal and fetal health during pregnancy.

Pregnancies resulting in twin deliveries cost 5 times as much as a singleton delivery, while pregnancies resulting in triplets or more cost nearly 20 times as much as a singleton delivery.16 Multiple gestations are a significant risk factor for preterm deliveries, resulting in significantly increased health care and other associated costs. On average, premature infant medical care results in an average of $51,500 in initial hospital costs (including neonatal intensive care costs), which does not include the long-term costs associated with prematurity.19  These long-term costs include early intervention resources, special education associated with the increased rates of disabilities, and loss of labor market productivity for the caregivers.19  Overall, states with IVF insurance have lower rates of multiple gestations and therefore less associated overall healthcare expenditures than states without IVF coverage.16 As Tricare and VA cover obstetrical care, they would also be impacted by the increased costs associated with multiple gestation.

Availability & Utilization

Opponents of universal TRICARE and VA coverage for assisted reproductive technology (ART) have argued that it may lead to overutilization of those services and increased expenditures, especially considering the cost of IVF.8  The data on the utilization of IVF services is limited in the US, because there has been no precedent for military coverage, and only 13 states currently mandate coverage for private insurers.  However, in states with IVF mandates, like Massachusetts and Illinois, the rate of IVF utilization was <0.8% in reproductive-aged women.17 In western countries, the estimated need for IVF has been around 1500 cycles per 1 million reproductive-age women, 25 to 45 years of age (1.5%); yet even in Denmark, which has the highest IVF treatment ratio, the utilization rate was approximately 1.2% among reproductive-age women.17 We can conclude from these examples that the availability of IVF leads to appropriate utilization of those services, but it does not appear to lead to overutilization; in fact, utilization appears to fall short of the overall demand.17

Conclusion

The psychosocial effects of infertility for individuals or couples who are unable to conceive biological children can be devastating.18 Military servicemembers and their families encounter unique challenges to family-building by spending many of their prime reproductive years in service, delaying their fertility plans, and facing potential chemical, physical and environmental hazards that could greatly impact fertility, yet health coverage of infertility services for veterans and active-duty military is very limited. In this article, we argue that in support of legislation to expand government-funded plans to cover IVF and other infertility-related services for active duty servicemembers and veterans. Expanded infertility coverage would be a pro-military pro-family initiative that would likely lead to higher retention of our active-duty military servicemembers, while simultaneously decreasing the overall rates of expensive care and alleviating the financial burden for military families navigating the already-stressful process of infertility treatment.

Supplemental Texts

VHA Directive 1334

DoD Policy Guidance

References

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