Infertility in the Military
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Updated May 26, 2021
Infertility in the Military
In recent years, Congress has become increasingly
8,744 were diagnosed with infertility from 2013 to 2018.
interested in the provision of infertility services and
During this same time period, the annual incidence rate of
expanded reproductive care for servicemembers. Federal
infertility diagnoses decreased by 25.3% (from 85.1 per
regulation (32 C.F.R. §199.4(g)) generally prohibits the
10,000 to 63.6 per 10,000 [see Figure 1]); while the
Department of Defense (DOD) from paying for certain
average annual prevalence of diagnosed female infertility
infertility services for most servicemembers and other
decreased by 18% (from 173.6 per 10,000 to 142.3 per
beneficiaries eligible for the TRICARE program. Some
10,000 [see Figure 2]).
Members of Congress argue that TRICARE coverage of
Figure 1. Annual incidence rates of female infertility
infertility services is an essential benefit to recruit and
diagnoses, active component servicewomen of
retain an all-volunteer force, while others express concern
childbearing potential, 2013-2018
that expanded coverage would make the benefit too costly.
This In Focus describes the prevalence of infertility among
servicemembers, available treatment options, and
considerations when addressing expanded TRICARE
coverage of infertility services for servicemembers.
Background
The U.S. Centers for Disease Control and Prevention
(CDC), defines infertility as “not being able to conceive
after one year of regular, unprotected sexual intercourse.”
Some health care providers, military and civilian, choose to
evaluate and treat females over age 35 after 6 months of
unprotected intercourse. Any condition affecting the
ovaries, fallopian tubes and/or uterus can result in infertility
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
Source: Defense Health Agency (DHA), Armed Forces Health
radiation, exposure to environmental toxins , excessive
Surveil ance Branch (AFHSB), “Female Infertility, Active Component
physical stress, or emotional stress are all risk factors
Service Women, U.S. Armed Forces, 2013-2018,” Medical Surveil ance
associated with increased infertility. CDC estimates that
Monthly Report, vol. 26, no. 6 (June 2019), p. 23.
16.8% of married females in the United States, aged 25-44,
Figure 2. Annual prevalence rates of female infertility
experienced infertility and received infertility services. In
diagnoses, active component servicewomen of
men (of the same age group), CDC estimates that 9.4%
childbearing potential, 2013-2018
experienced and received infertility services.
In 2015, then-Secretary of Defense (SECDEF) Ashton
Carter introduced the “Force of the Future” (FoTF)
initiative aimed at maintaining DOD’s “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 parents, including their ability
to start and support families . 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.
In June 2019, DOD reported on the incidence (i.e., rate of
new cases) and prevalence (i.e., proportion of cases in the
military at a given time) of diagnosed infertility among
active duty females. An incident of infertility was defined
Source: Ibid, p. 25.
as “having at least 2 outpatient medical encounters with an
infertility diagnosis .” The report showed that diagnoses of
Notes: aBlock, occlusion, or stenosis of the fal opian tubes.
b
female infertility decreased from 2013 to 2018 despite an
Structural abnormality of the uterus or nonimplantation (includes
increase in the number of females tested for infertility. Of
fibroids).
the more than 200,000 total active female servicemembers,
https://crsreports.congress.gov
Infertility in the Military
DOD also found that some groups of females were at higher
Moral or Religious Objections
risk for infertility. Infertility diagnoses were highest among
There are certain moral or conscience issues surrounding
non-Hispanic Black servicemembers over age 30. The
general ART therapies, particularly around assisted
Army had the highest incidence rate (101.7 per 10,000) of
methods to develop embryos and the disposal of unused
infertility diagnoses, while the Marine Corps had the lowest
embryos. In 2019, CDC reported 77,998 live births from
incidence rate (50.4 per 10,000). Active duty female
330,773 ART cycles (23.5% ART cycle success rate). In
servicemembers in health care occupations had the highest
each ART cycle 15-20 embryos are created and 1-4
incidence followed by pilots and air crew.
embryos are used. The rest of the embryos are frozen for
Treatment Options
later use, donated to research, or discarded. This process,
CDC recommends treating infertility with medicine,
occurring in the early stages of development, is seen by
surgery, or assisted reproductive technology (ART). DOD
some as contrary to religious beliefs , and akin to abortion.
offers certain counseling and treatment services for
Others say this process is moral and that ethical disposal
infertility, when medically necessary and combined with
procedures are used to discard unused embryos.
natural conception, including:
Recruitment and Retention
correction of any physical cause of infertility;
In general, the military services have lower retention of
erectile dysfunction if it has a physical cause; or
females than males. A 2018 RAND Corporation report on
diagnostic services (e.g., semen analysis, hormone
Air Force female officer retention found that the lack of
evaluation, chromosomal studies, immunologic studies,
family and personal life affects their retention. Some argue
special and sperm function tests, or bacteriologic
that if the military is going to recruit and retain diverse
investigation).
talent from across the nation, it must offer services and
benefits that are commensurate with the civilian job market.
In general, DOD does not cover ART services, such as:
Others argue that military health care is already costly and
more generous than many civilian health plans. Some point
artificial or intrauterine insemination;
to expanding adoption services for infertile military couples
costs related to donors or semen banks;
as an additional benefit Congress could offer.
reversal of tubal ligation or vasectomy, unless medically
necessary;
Defense Health Program Costs
In 2015, a Congressional Budget Office (CBO) cost
care for erectile dysfunction from psychological causes
estimate of a version of the FY2016 NDAA (H.R. 1735)
including depression, anxiety, and stress; or
forecast that TRICARE coverage of ART services would
non-coital reproductive procedures including in vitro
increase DOD discretionary spending by $175 million
fertilization (IVF), gamete intrafallopian transfer, zygote
annually. CBO said, “TRICARE would incur additional
intrafallopian transfer, and tubal embryo transfer.
costs for the increased number of pregnancies resulting
At select DOD hospitals, limited ART services (e.g., sperm
from those procedures,” estimated at $100 million annually.
or egg retrieval; IVF; artificial insemination; or egg, sperm
Military family advocates argue that the recruitment and
or embryo cryopreservation) are available to seriously ill or
retention numbers ART services could render outweighs the
injured active duty servicemembers and their spouses, with
cost of an expanded health care benefit.
a qualifying diagnosis (e.g., infertility). These services may
also be available to other servicemembers on a space-
Relevant Statutes
available and cost-sharing basis.
Title 10, U.S. Code, Chapter 55 – Medical and Dental Care
Patient Costs
Title 32, Code of Federal Regulations, Part 199 – Civilian
Active duty servicemembers incur no out-of-pocket costs
Health and Medical Program of the Uniformed Services
for health care services covered by DOD’s health benefits
CRS Products
program—also known as TRICARE. With the exception of
ART services available to seriously ill or injured active
CRS In Focus IF11109, Defense Health Primer: Contraceptive
duty servicemembers and their spouses, TRICARE does not
Services, by Bryce H. P. Mendez
cover ART services. Servicemembers seeking ART
CRS Report R46785, Federal Support for Reproductive Health
services from civilian health care providers must pay out-
Services: Frequently Asked Questions, coordinated by Elayne J.
of-pocket for this care. The Society for Assisted
Heisler
Reproductive Technology estimates that the average cost of
Other Resources
one IVF cycle (i.e., egg/sperm harvest, fertilization, and
implantation) in the United States ranges from $10,000 to
U.S. Centers for Disease Control and Prevention. 2017
$15,000. In comparison, space-available IVF services at
Assisted Reproductive Technology Fertility Clinic Success Rates
select DOD hospitals (e.g., Walter Reed ART Institute)
Report. Atlanta (GA): US Dept. of Health and Human Services;
range from $4,800 to $7,000 per cycle.
2019.
Considerations for Congress
Office of the Secretary of Defense, “Report to Congress
Efforts to Treat Infertility of Military Families,” 2015.
Congress may debate on legislation that would expand or
limit the provision of infertility services to servicemembers
and in doing so, could face a number of considerations
when addressing these issues.
Bryce H. P. Mendez, Analyst in Defense Health Care
Policy
https://crsreports.congress.gov
Infertility in the Military
IF11504
Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan shared staff to
congressional committees and Members of Congress. It operates solely at the behest of and under the direction of Congress.
Information in a CRS Report should not be relied upon for purposes other than public understanding of information that has
been provided by CRS to Members of Congress in connection with CRS’s institutional role. CRS Reports, as a work of the
United States Government, are not subject to copyright protection in the United States. Any CRS Report may be
reproduced and distributed in its entirety without permission from CRS. However, as a CRS Report may include
copyrighted images or material from a third party, you may need to obtain the permissio n of the copyright holder if you
wish to copy or otherwise use copyrighted material.
https://crsreports.congress.gov | IF11504 · VERSION 3 · UPDATED
Updated May 26, 2021
Infertility in the Military
In recent years, Congress has become increasingly
8,744 were diagnosed with infertility from 2013 to 2018.
interested in the provision of infertility services and
During this same time period, the annual incidence rate of
expanded reproductive care for servicemembers. Federal
infertility diagnoses decreased by 25.3% (from 85.1 per
regulation (32 C.F.R. §199.4(g)) generally prohibits the
10,000 to 63.6 per 10,000 [see Figure 1]); while the
Department of Defense (DOD) from paying for certain
average annual prevalence of diagnosed female infertility
infertility services for most servicemembers and other
decreased by 18% (from 173.6 per 10,000 to 142.3 per
beneficiaries eligible for the TRICARE program. Some
10,000 [see Figure 2]).
Members of Congress argue that TRICARE coverage of
Figure 1. Annual incidence rates of female infertility
infertility services is an essential benefit to recruit and
diagnoses, active component servicewomen of
retain an all-volunteer force, while others express concern
childbearing potential, 2013-2018
that expanded coverage would make the benefit too costly.
This In Focus describes the prevalence of infertility among
servicemembers, available treatment options, and
considerations when addressing expanded TRICARE
coverage of infertility services for servicemembers.
Background
The U.S. Centers for Disease Control and Prevention
(CDC), defines infertility as “not being able to conceive
after one year of regular, unprotected sexual intercourse.”
Some health care providers, military and civilian, choose to
evaluate and treat females over age 35 after 6 months of
unprotected intercourse. Any condition affecting the
ovaries, fallopian tubes and/or uterus can result in infertility
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
Source: Defense Health Agency (DHA), Armed Forces Health
radiation, exposure to environmental toxins , excessive
Surveil ance Branch (AFHSB), “Female Infertility, Active Component
physical stress, or emotional stress are all risk factors
Service Women, U.S. Armed Forces, 2013-2018,” Medical Surveil ance
associated with increased infertility. CDC estimates that
Monthly Report, vol. 26, no. 6 (June 2019), p. 23.
16.8% of married females in the United States, aged 25-44,
Figure 2. Annual prevalence rates of female infertility
experienced infertility and received infertility services. In
diagnoses, active component servicewomen of
men (of the same age group), CDC estimates that 9.4%
childbearing potential, 2013-2018
experienced and received infertility services.
In 2015, then-Secretary of Defense (SECDEF) Ashton
Carter introduced the “Force of the Future” (FoTF)
initiative aimed at maintaining DOD’s “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 parents, including their ability
to start and support families . 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.
In June 2019, DOD reported on the incidence (i.e., rate of
new cases) and prevalence (i.e., proportion of cases in the
military at a given time) of diagnosed infertility among
active duty females. An incident of infertility was defined
Source: Ibid, p. 25.
as “having at least 2 outpatient medical encounters with an
infertility diagnosis .” The report showed that diagnoses of
Notes: aBlock, occlusion, or stenosis of the fal opian tubes.
b
female infertility decreased from 2013 to 2018 despite an
Structural abnormality of the uterus or nonimplantation (includes
increase in the number of females tested for infertility. Of
fibroids).
the more than 200,000 total active female servicemembers,
https://crsreports.congress.gov
Infertility in the Military
DOD also found that some groups of females were at higher
Moral or Religious Objections
risk for infertility. Infertility diagnoses were highest among
There are certain moral or conscience issues surrounding
non-Hispanic Black servicemembers over age 30. The
general ART therapies, particularly around assisted
Army had the highest incidence rate (101.7 per 10,000) of
methods to develop embryos and the disposal of unused
infertility diagnoses, while the Marine Corps had the lowest
embryos. In 2019, CDC reported 77,998 live births from
incidence rate (50.4 per 10,000). Active duty female
330,773 ART cycles (23.5% ART cycle success rate). In
servicemembers in health care occupations had the highest
each ART cycle 15-20 embryos are created and 1-4
incidence followed by pilots and air crew.
embryos are used. The rest of the embryos are frozen for
Treatment Options
later use, donated to research, or discarded. This process,
CDC recommends treating infertility with medicine,
occurring in the early stages of development, is seen by
surgery, or assisted reproductive technology (ART). DOD
some as contrary to religious beliefs , and akin to abortion.
offers certain counseling and treatment services for
Others say this process is moral and that ethical disposal
infertility, when medically necessary and combined with
procedures are used to discard unused embryos.
natural conception, including:
Recruitment and Retention
correction of any physical cause of infertility;
In general, the military services have lower retention of
erectile dysfunction if it has a physical cause; or
females than males. A 2018 RAND Corporation report on
diagnostic services (e.g., semen analysis, hormone
Air Force female officer retention found that the lack of
evaluation, chromosomal studies, immunologic studies,
family and personal life affects their retention. Some argue
special and sperm function tests, or bacteriologic
that if the military is going to recruit and retain diverse
investigation).
talent from across the nation, it must offer services and
benefits that are commensurate with the civilian job market.
In general, DOD does not cover ART services, such as:
Others argue that military health care is already costly and
more generous than many civilian health plans. Some point
artificial or intrauterine insemination;
to expanding adoption services for infertile military couples
costs related to donors or semen banks;
as an additional benefit Congress could offer.
reversal of tubal ligation or vasectomy, unless medically
necessary;
Defense Health Program Costs
In 2015, a Congressional Budget Office (CBO) cost
care for erectile dysfunction from psychological causes
estimate of a version of the FY2016 NDAA (H.R. 1735)
including depression, anxiety, and stress; or
forecast that TRICARE coverage of ART services would
non-coital reproductive procedures including in vitro
increase DOD discretionary spending by $175 million
fertilization (IVF), gamete intrafallopian transfer, zygote
annually. CBO said, “TRICARE would incur additional
intrafallopian transfer, and tubal embryo transfer.
costs for the increased number of pregnancies resulting
At select DOD hospitals, limited ART services (e.g., sperm
from those procedures,” estimated at $100 million annually.
or egg retrieval; IVF; artificial insemination; or egg, sperm
Military family advocates argue that the recruitment and
or embryo cryopreservation) are available to seriously ill or
retention numbers ART services could render outweighs the
injured active duty servicemembers and their spouses, with
cost of an expanded health care benefit.
a qualifying diagnosis (e.g., infertility). These services may
also be available to other servicemembers on a space-
Relevant Statutes
available and cost-sharing basis.
Title 10, U.S. Code, Chapter 55 – Medical and Dental Care
Patient Costs
Title 32, Code of Federal Regulations, Part 199 – Civilian
Active duty servicemembers incur no out-of-pocket costs
Health and Medical Program of the Uniformed Services
for health care services covered by DOD’s health benefits
CRS Products
program—also known as TRICARE. With the exception of
ART services available to seriously ill or injured active
CRS In Focus IF11109, Defense Health Primer: Contraceptive
duty servicemembers and their spouses, TRICARE does not
Services, by Bryce H. P. Mendez
cover ART services. Servicemembers seeking ART
CRS Report R46785, Federal Support for Reproductive Health
services from civilian health care providers must pay out-
Services: Frequently Asked Questions, coordinated by Elayne J.
of-pocket for this care. The Society for Assisted
Heisler
Reproductive Technology estimates that the average cost of
Other Resources
one IVF cycle (i.e., egg/sperm harvest, fertilization, and
implantation) in the United States ranges from $10,000 to
U.S. Centers for Disease Control and Prevention. 2017
$15,000. In comparison, space-available IVF services at
Assisted Reproductive Technology Fertility Clinic Success Rates
select DOD hospitals (e.g., Walter Reed ART Institute)
Report. Atlanta (GA): US Dept. of Health and Human Services;
range from $4,800 to $7,000 per cycle.
2019.
Considerations for Congress
Office of the Secretary of Defense, “Report to Congress
Efforts to Treat Infertility of Military Families,” 2015.
Congress may debate on legislation that would expand or
limit the provision of infertility services to servicemembers
and in doing so, could face a number of considerations
when addressing these issues.
Bryce H. P. Mendez, Analyst in Defense Health Care
Policy
https://crsreports.congress.gov
Infertility in the Military
IF11504
Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan shared staff to
congressional committees and Members of Congress. It operates solely at the behest of and under the direction of Congress.
Information in a CRS Report should not be relied upon for purposes other than public understanding of information that has
been provided by CRS to Members of Congress in connection with CRS’s institutional role. CRS Reports, as a work of the
United States Government, are not subject to copyright protection in the United States. Any CRS Report may be
reproduced and distributed in its entirety without permission from CRS. However, as a CRS Report may include
copyrighted images or material from a third party, you may need to obtain the permissio n of the copyright holder if you
wish to copy or otherwise use copyrighted material.
https://crsreports.congress.gov | IF11504 · VERSION 3 · UPDATED