April 15, 2020
Infertility in the Military
Six bills introduced in the 116th Congress aim to expand
cases in military at a given time) of diagnosed female
infertility health care services to servicemembers. Congress
infertility among active duty females . An incident of
has become increasingly interested in this health care
infertility was defined by “having at least 2 outpatient
benefit, because infertility care is not a TRICARE-covered
medical encounters with an infertility diagnosis”. The
benefit and an increased number of female servicemembers
report showed that diagnoses of female infertility decreased
and members of the public are interested in reproductive
from 2013 to 2018 despite an increase in the number of
care. Some Members of Congress argue that health care
females tested for infertility. Of the more than 200,000 total
coverage for service-connected disabilities and family
active female servicemembers, 8,744 were diagnosed with
reproductive care is essential to both recruitment and
infertility from 2013 to 2018. The annual incidence rate of
retention in the armed services. Others say the variety of
infertility diagnoses decreased by 25.3% (from 85.1 per
modern treatments available would make the benefit too
10,000 to 63.6 per 10,000) during this five-year period (see
costly.
Figure 1). From 2013 to 2018, the average annual
prevalence of diagnosed female infertility was 1.6%
Background
(number of active duty females with infertility at one time).
The U.S. Centers for Disease Control and Prevention
This annual prevalence is considerably lower than what was
(CDC), defines infertility as “not being able to conceive
found by the SWAN survey, which estimated infertility
after one year of regular, unprotected sexual intercourse.”
rates based on self-reporting.
Some providers, military and civilian, choose to evaluate
and treat females over age 35 after six months of
Figure 1. Annual incidence rates of female infertility
unprotected intercourse. Any condition affecting the
diagnoses, active component service women of
ovaries, fallopian tubes and/or uterus can result in infertility
childbearing potential, 2013-2018
among females. Hormonal disorders or disruptions to
testicular function can cause infertility in men. Increased
age, smoking, excessive alcohol use, extreme weight gain
or loss, sexually transmitted infections, exposure to
radiation, exposure to environmental toxins , excessive
physical stress, or emotional stress are all risk factors
associated with increased infertility. CDC estimates that
6.7% of married females aged 15-44 experience infertility
in the United States.
In 2015, then-Secretary of Defense (SECDEF) Ashton
Carter introduced the “Force of the Future” (FoTF)
initiative aimed at “maintaining the Department of
Defense’s (DOD) competitive edge in bringing in top talent
to serve the nation.” The goal of the FoTF was to recruit
and retain a diverse and talented military. One aspect of the
FoTF initiative was improving the quality of life of military
Source: DOD Report, “Female Infertility, Active Component
parents, including their ability to start and support families .
Service Women, U.S. Armed Forces, 2013-2018,” June, 1 2019.
The new benefits included expanded adoption leave and a
trial egg and sperm cryopreservation program. The
department ended its pursuit of this initiative in 2017.
While DOD found the incidence of diagnosed infertility to
be decreasing, there were some groups of females found to
Infertility among female servicemembers garnered attention
be at higher risk. Infertility diagnoses were highest among
in 2018 when the Service Women’s Action Network
non-hispanic black servicemembers over age 30. The Army
(SWAN) reported on the experiences of military females
had the highest incidence rate (101.7 per 10,000) of
who attempt to access reproductive care. The report was
infertility diagnoses, while the Marine Corps had the lowest
based on a survey that SWAN conducted of 799 military
incidence rate (50.4 per 10,000). Active duty female
females, including 262 active duty females (<1% of the
servicemembers in health care occupations had the highest
active duty female population). With regard to infertility,
incidence followed by pilots and air crew. Health care
37% of active duty respondents to the survey said they had
personnel may be more likely to seek care, while pilots and
trouble getting pregnant when actively trying to do so.
air crew may be at higher risk due to radiation or physical
job demands.
In response, DOD reported in June 2019 on the incidence
(i.e., rate of new cases) and prevalence (i.e., proportion of
https://crsreports.congress.gov
Infertility in the Military
Treatment Options
Moral/ Religious Objections
CDC recommends treating infertility with medicine,
There are certain moral or conscience issues surrounding
surgery, or assisted reproductive technology (ART).
general ART therapies, particularly around assisted
Medical professionals determine the best treatment for
methods to develop embryos and the disposal of unused
infertility based upon the duration of infertility, the age of
embryos. In 2017, CDC reported 78,052 births from
the patient, and the factors contributing to infertility and the
284,385 ART cycles (27.4% ART cycle success rate). In
treatment preference of the patient.
each ART cycle 15-20 embryos are created and 1-4
DOD offers certain infertility treatment services for active
embryos are used. The rest of the embryos are frozen for
duty servicemembers or their spouses, such as:
later use, donated to research or discarded. This process,
occurring in the early stages of development, is seen by
for erectile dysfunction if it has a physical cause; or
some as contrary to religious beliefs, and akin to abortion.
diagnostic services including: semen analysis, hormone
Others say this process is moral and that ethical disposal
evaluation, diagnosis and treatment for illness or injury
procedures are used to discard unwanted embryos.
to reproductive system;
Recruitment and Retention
care chromosomal studies, immunologic studies, special
and sperm function tests, and bacteriologic
All four services have lower retention of females than
investigation.
males. The RAND Corporation released a study in 2018 on
Air Force female officer retention. RAND found that the
In general, DOD healthcare benefits do not cover:
lack of family and personal life affects female officer
artificial or intrauterine insemination;
retention. Some argue that if the military is going to recruit
costs related to donors or semen banks;
and retain diverse talent from across the nation, it must
offer services and benefits that are commensurate with
reversal of tubal ligation or vasectomy, unless medically
necessary;
those open to civilians. Others argue that military health
care is already costly and more advantageous than many
care for erectile dysfunction from psychological causes
civilian health plans. Some point to expanding adoption
including: depression, anxiety, and stress; or
services for military couples suffering from infertility as an
non-coital reproductive procedures including: in vitro
additional benefit Congress could offer.
fertilization (IVF), gamete intrafallopian transfer, zygote
intrafallopian transfer, and tubal embryo transfer.
Defense Health Program Costs
Nevertheless, DOD does offer some infertility services,
In 2015, a Congressional Budget Office (CBO) cost
such as IVF, intracytoplasmic sperm injection, and
estimate of the FY2016 NDAA (H.R. 1735) forecast that
intrauterine insemination at some of its larger military
TRICARE coverage of ART services would increase DOD
treatment facilities, that servicemembers can purchase out
discretionary spending by $175 million annually. CBO said,
of pocket.
“TRICARE would incur additional costs for the increased
Patient Costs
number of pregnancies resulting from those procedures,”
Active duty servicemembers incur no out-of-pocket costs
estimated at $100 million annually. Military family
for health care services covered by DOD’s health benefits
advocates and service women’s action groups say these
program—also known as TRICARE. With the exception of
costs are outweighed by the recruitment and retention
infertility treatments needed due to service-related injuries,
numbers ART services could render.
TRICARE does not cover ART services. Servicemembers
seeking ART services from civilian health care providers
Relevant Statutes
must pay out-of-pocket for this care. IVF treatment at
Title 10, U.S. Code, Chapter 55 – Medical and Dental Care
Walter Reed ART Institute ranges from $4,800 to $7,000.
Title 32, Code of Federal Regulations, Part 199 – Civilian Health
The cost of treatment is determined by the male evaluation
test (semen viability analysis) and by the specific services
and Medical Program of the Uniformed Services
provided. At the Walter Reed ART Institute, each payment
CRS Products
is for one treatment cycle of IVF (i.e., egg/sperm harvest,
CRS In Focus IF11109, Defense Health Primer: Contraceptive
fertilization, and implantation).
Services, by Bryce H. P. Mendez
Considerations for Congress
Other Resources
Senate Armed Services Committee report, S.Rept. 116-48,
accompanying the FY2020 National Defense Authorization
U.S. Centers for Disease Control and Prevention. 2017 Assisted
Act (NDAA; P.L. 116-92) directs the SECDEF to conduct a
Reproductive Technology Fertility Clinic Success Rates Report. Atlanta
study on the incidence of infertility among servicemembers
(GA): US Dept of Health and Human Services; 2019.
and provide a report to the Armed Services Committees no
Office of the Secretary of Defense, “Report to Congress Efforts
later than June 1, 2020. Required elements of the report
to Treat Infertility of Military Families”, December 2015.
include the number of current servicemembers diagnosed
with infertility, the incidence of miscarriages among female
servicemembers, comparison to the infertility rates of
civilian counterparts, criteria for determining service-
Emily K. Lane, Defense Health Policy Fellow
connection for infertility and the availability of infertility
IF11504
services. Congress may face a number of considerations
when addressing these issues.
https://crsreports.congress.gov
Infertility in the Military
Disclaimer
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