Women in the Military Face Unique Fertility Challenges

Fertility concerns are tough to face no matter what your profession or position in life. But infertility for people in the military may bring many additional complexities to consider.

This is the first of two articles delving into infertility challenges in the U.S. military. Due to myriad factors to discuss, we decided to look at infertility separately for men and women in the military. This first part focuses on infertility among servicewomen.

Before you join the military, it's unlikely that fertility or your plans to have a family factor into your decision to serve. But it's an important topic to consider.

"Military families work and live under a unique set of circumstances that create unique challenges to becoming parents, and with appropriate clinical support, these obstacles can be overcome," explained Roger Shedlin, M.D., J.D., president and CEO of WINFertility, a family-building solutions company headquartered in Greenwich, Connecticut.

Research indicates that military women face three key factors that can cause infertility due to active service:

1. Use of psychiatric medications for post-traumatic stress disorder (PTSD)
2. Exposure to toxins
3. A higher-than-average rate of reported sexual trauma

These three elements don't take into account time away on deployments, physical trauma, the physiological stress of specific roles and difficulty accessing fertility services. Higher levels of tobacco and alcohol use have also been highlighted as contributing factors impacting the fertility of servicewomen.

It's a complex set of circumstances to analyze.

A 2018 survey by the Service Women's Action Network (SWAN) of almost 800 National Guard members, reservists, retirees and veterans indicated that 37 percent of active-duty respondents experienced infertility. This compares with 12 percent in the general population, or 1 in 8 couples. Thirty percent of the women who responded to the survey stated they struggled to conceive a child. It must be noted that the small sample size of this survey is a significant limitation and perhaps not fully representative.

Other reports have not identified this high incidence of infertility in military women. A 2019 study published by Health.mil, the official website of the Military Health System, looked at the incidence of diagnosed female infertility among active-duty U.S. service members between 2013 and 2018 and suggested a prevalence of just 1.6 percent. This is much lower than the results of the SWAN study. The report discussed its limitations and stated diagnoses of infertility may underestimate the true incidence and prevalence of this condition.

Two-thirds (67 percent) of military families reported challenges with family building, including a lack of medical coverage for fertility-related treatments, according to the 2021 Blue Star Families Military Family Lifestyle Survey, which included more than 8,000 respondents. Twenty-three percent of active-duty service members and 27 percent of active-duty spouses reported fertility challenges, though the reported data does not distinguish between male and female members.

Twenty-five percent of active-duty service members and 34 percent of active-duty spouses reported miscarriage and 2 percent in both categories reported stillbirth. The survey authors noted that the proportion of active-duty spouse respondents reporting a lifetime experience of miscarriage is notably higher than the lifetime prevalence of miscarriage among civilian populations, which stands at 26 percent.

Few studies specifically look at infertility in women who serve in the military, but here are some general statistics to try to build a picture:

• The prevalence of lifetime history of infertility in veterans was 15.8 percent for women and 13.8 percent for men, according to data from the Department of Veteran Affairs.
• Comparison of infertility in the civilian population is difficult due to varying definitions of infertility and study designs. The National Survey of Family Growth provided statistics on married women ages 15 to 49 who are infertile. Prevalence ranged from 6 percent to 6.5 percent across the ages. Twelve percent of women ages 15 to 49 reported receiving fertility services.
• There is even less data available for infertility in men. Almost 9 percent of U.S. men ages 25 to 44 said they or their partner saw a doctor for advice, testing or treatment for infertility during their lifetime, according to the Centers for Disease Control and Prevention (CDC).
• The military and veteran healthcare systems offer limited treatment options for couples facing infertility. No coverage is provided for proactive fertility preservation.

In light of the data, questions arise about why women in the military face a greater possibility of infertility problems and why the subject isn't discussed more often.

Shedlin noted that during deployment, spouses may be separated from their partners for months or more at a time.

"Their opportunities for having traditional coital sex are fewer than the general population, and many turn to IVF [in vitro fertilization] to have children," he said.

But IVF comes with challenges, as do surrogacy and adoption. The frequent relocation of service members, who often move every three to four years, makes it difficult to take advantage of these options.

The Military Family Lifestyle Survey noted that the military lifestyle introduces unique challenges to family building, including unpredictable separations between partners, disruptions to treatment due to relocation and/or deployment, and challenges accessing care due to the location of duty stations and lack of coverage for potential treatments.

Forty-two percent of active-duty family respondents reported that military service created challenges to having children, the desired number of children and/or the desired spacing of children.

Additionally, TRICARE, the military medical insurance provider, doesn't reimburse infertility treatments―defined as anything other than noncoital reproduction done for the purpose of having children―unless the service member had a serious illness or injury while on active duty which caused him or her to lose natural reproductive ability.

We'll discuss fertility treatments and other family-building limitations in-depth later, but it's important to note that this lack of financial and medical support for family building has unintended consequences: It unnecessarily jeopardizes the most reliable method of military recruitment.

The New York Times reported in 2020 that 79 percent of U.S. Army recruits came from a military family and 30 percent had a military parent. Including the other branches, approximately 70 percent of serving troops come from military families.

"Limiting military parents' ability to have children harms this essential recruiting pipeline," Shedlin said.

You may know that women are born with all the eggs they will ever have. What does this mean for women who are exposed to the toxins, physical exertion and mental health stressors involved with serving in the military?

Both men and women with PTSD are more likely to have problems with sexual dysfunction, according to a 2015 study published in the Journal of Sexual Medicine and sponsored by Veterans Affairs. The study discussed that the brain connects arousal with aggression. Therefore, a person with PTSD can feel threatened when aroused rather than open to pleasure.

In addition, if someone is being treated for PTSD, the medication they are prescribed may have a negative impact on fertility, explained Ramy A. Ghayda, M.D., chief medical officer at Legacy, a Boston-based fertility company. For women, PTSD medication can alter their menstrual cycle and also affect libido.

In an interview with Giddy, Patricia Hayes, Ph.D., the chief officer of women's health for the Veterans Health Administration in the U.S. Department of Veterans Affairs in Washington, D.C., raised a few important points about women who suffer blast injuries in combat.

"We don't see the entire population of women who served in the Department of Defense, so we don't know the whole picture of women who experienced genital and abdominal injuries from improvised explosive devices [IEDs]," she explained. Therefore, the department doesn't have any data on this topic.

Hayes said it's hypothesized that if a woman faces a blast that is likely to damage her reproductive system, it is unlikely she would survive. On the other hand, it's also possible that the abdominal fat offers a protective element, meaning less reproductive injury caused by IEDs.

Another result of blast injuries to factor in is a traumatic brain injury, Hayes said. According to the brain injury association Headway, traumatic brain injury can cause decreased libido, decreased arousal, reduced fertility and reproductive changes, such as irregular menstrual cycles.

An estimated 1 in 4 female veterans report military sexual trauma―sexual assault or harassment occurring during military service―according to Disabled American Veterans. This can lead to PTSD, challenges with relationships and sexual difficulties. PTSD and military sexual trauma may be associated with sexual dysfunction, which can be a cause of infertility if the military member or veteran is unable to have intercourse.

Another important consideration for servicewomen is that the number and quality of eggs released decreases with age. Many women in the military delay pregnancies until their 30s and 40s. Between 2012 and 2016, the prevalence of pregnancy among female service members ages 35 to 39 increased from 10.7 percent to 11.7 percent.

These potential contributors to infertility problems run alongside deployments, exposure to toxins, such as burn pits that release dioxin and other toxins, and the physical stress of military training.

For most people, regular exercise is a positive activity for promoting fertility. Tommy's, a charity in the United Kingdom that researches pregnancy complications, noted that women accustomed to vigorous, intense exercise are usually not affected by infertility. However, the organization highlighted that some women, such as elite athletes, who have a low or healthy body mass index (BMI) and do vigorous, intense exercise on most days can be affected by infertility.

This effect may apply to women serving in specific physically intensive roles in the military. A 2021 paper on basic military training published in the American Journal of Physiology-Endocrinology and Metabolism indicated that servicewomen noticed fewer periods, and rates of ovulation were very low.

The researchers noted this was likely a temporary adaptation, known as hypothalamic amenorrhoea. In female athletes, this phenomenon is commonly seen when athletes eat insufficient calories to compensate for the amount of exercise they are doing. This can also cause bone thinning, or osteopenia, which together with amenorrhea and disordered eating comprise the female athlete triad. The research suggested no evidence of the female athlete triad in military training. On the contrary, bone health improved, and women put weight on, being slightly heavier at the end of training than at the start. They also became fitter and stronger.

The research team, led by Robert M. Gifford, M.B.Ch.B., Ph.D., a physician with the Royal Air Force and honorary lecturer at the University of Edinburgh's Centre for Cardiovascular Science in Scotland, hypothesized that other stressful factors, such as sleep disturbance―women often sleep only four to six hours per night during training―an external locus of control or cultural pressures, were more likely to have led to these changes in reproductive function.

Now that we understand the stress put on a woman's mind and body that can lead to fertility concerns, let's look at the support provided to women serving in the military.

Healthcare coverage for the U.S. military is a bit complex, but the basic breakdown is as follows:

• TRICARE (Department of Defense) is the health coverage available to active-duty personnel, reserves, National Guard members and retirees.
• The Department of Veterans Affairs (VA) provides health coverage to discharged veterans (nonretirees).

"The biggest friction point to accessing fertility care through military health coverage is that you have to prove that your condition or injury is service-related and medically necessary," explained Capt. John Crowley, head of military affairs at Legacy. Since fertility is multifactorial, it's difficult in most cases to pinpoint a specific military-related cause, unless an injury is involved.

TRICARE covers basic diagnostics for fertility for active-duty members of the military. However, it doesn't cover fertility treatment unless the service member (male or female) is on active duty, had a serious illness or injury while on active duty (Category II or III), lost natural reproductive ability due to that illness or injury, and has a lawful spouse.

One IVF cycle can cost $15,000 to $35,000. Surrogacy, which is not covered by TRICARE, costs anywhere from $90,000 to $130,000, and may include IVF treatment and medical costs for the surrogate, plus legal fees, travel and insurance expenses. Fertility preservation is not covered despite military members being more at-risk for infertility.

The VA and the Department of Defense (DOD) both offer adoption reimbursement covered under federal law, but this is limited to $2,000 per child. Adoption fees typically start at $50,000. For reference, a sergeant in the Marines must have at least eight years of cumulative service to make even $40,000 a year.

Eleven percent of active-duty family respondents to the Military Family Lifestyle Survey reported out-of-pocket expenses of $35,000 or more associated with family-building issues, including adoption, medical treatments, surrogacy and/or fostering to adopt. These challenges are intensified for same-sex military couples and single service members, who do not qualify for certain types of family-building care under current DOD restrictions.

When veterans leave the military, they can instead access health care provided by Veteran Affairs.

"VA typically provides service to veterans who are eligible and enrolled in VA services," said Amanda Johnson, M.D., director of women's reproductive health in the VA's office of women's health. "Approximately 900,000 women veterans are enrolled and about 600,000 women veterans use VA health care in the United States in a given year."

Generally, IVF is excluded from the VA medical benefits package, however, under recent law, IVF is covered for some veterans and their spouses. Eligibility is determined by having a service-connected disability with a medical diagnosis of infertility and clinical judgment of the healthcare provider.

Surrogacy, as well as donated sperm or eggs, is not covered benefits. The policy is based on law which limits the VA to following 2012 DOD policies, most recently reapproved Jan. 5, 2021. This policy makes accessing fertility and family-building options even more challenging for LGBTQIA+ service members and veterans.

A new national organization, the Military Family Building Coalition (MFBC), is the first to take on the issues of family building and infertility and was co-founded by Katy Bell Hendrickson and Ellen Gustafson. Bell Hendrickson, the spouse of a former Naval Special Warfare officer, utilized IVF, adoption and surrogacy to build her family. Gustafson, also a Navy spouse, needed IVF to have her twins after a genetic issue caused a stillbirth while her husband was deployed.

"There was no support throughout our infertility challenges and treatments," Bell Hendrickson said. "We never really got a formal diagnosis of infertility. It was 100 percent 'do it yourself.' Both Ellen and I have stepped back many times and asked, 'How does anyone do this?' Building a family was truly one of the hardest things we have done in our military careers."

Gustafson said there was little, if any, conversation within military support organizations about service members potentially facing higher infertility rates than their civilian counterparts.

"There was a hole in the support that no one saw and no one was filling," Gustafson said.

"We know that the military work environment has particularly high stressors, separates partners constantly, that there is exposure to toxins and hazardous materials," Bell Hendrickson said, adding that despite this, there is limited support for adoption, no financial offset for advanced reproductive technology, and a policy against providing care and coverage.

"There is little consideration for women in service and how they can have children and continue to commit to their careers," she said, adding that the problem is further compounded by the lack of language allowed for LGBTQIA+ service members to build a family.

She perceives an outdated understanding and culture of modern family building within the military.

"It is not inclusive, it is discriminatory, and it clearly doesn't address the connection that family building has with supporting war fighting," Bell Hendrickson stated.

She said supporting family building in the military is about readiness, retention, the economically smart thing to do, and how the U.S. maintains a voluntary force.

"There is really no value that you can put on becoming a parent," Bell Hendrickson said. "We want to look at Department of Defense policies, look at expanding TRICARE, and have conversations with Congress about making changes to this outdated system."

With this in mind, and the experience of their personal journeys, Bell Hendrickson and Gustafson co-founded the MFBC with the goal of expanding military families' access to family-building benefits.

The MFBC is a nonprofit organization committed to supporting military families through family building. Its vision is to help all active-duty service members and their partners build the families they want, regardless of deployment schedules, gender, fertility challenges or financial situation.

The coalition has set up several initiatives, including:

• Educating service members about infertility, adoption and fertility preservation support.
• Educating the public about the additional family-building and infertility challenges faced by military members and the lack of support available.
• Supporting military members' cryopreservation, fertility treatments and adoptions.
• Advocating for healthcare and policy change.
• The Tadpole Project, which brings advanced solutions and comprehensive family-building counseling to the Naval Special Warfare community.
• The AVIATRIX Project, a pilot program to offer family-building support services to 500 service members.

The MFBC partnered with private-sector fertility benefits manager WINFertility on the AVIATRIX Project, which targets female naval aviators and naval aviation personnel, who have highly challenging constraints for family building amid deployments, training and operational demands.

"In our pilot program for females in aviation, we have seen up close the challenges of flying and continuing to work while navigating any family-building process," Gustafson said. "If women have access to fertility services and procedures and help in planning their own family building, it will be easier for them to stay mission-ready and continue to work toward leadership positions, like their male counterparts who become parents."

The services offered in the AVIATRIX Project and delivered by WINFertility include:

• 24/7 clinical support through WINFertility nurse care managers
• Reproductive behavioral wellness
• Access to the WINFertility network of medical and pharmacy providers
• Guided counseling on family-building options

"Many women choose to leave the military right at the peak of their career, and after extensive investment from the military, due to lack of family-building support and options," Bell Hendrickson said. "Great talent is lost to the private sector with better health care and maternity coverage. Retaining these experienced women is how we build leadership that reflects the diversity of serving military members."

The program empowers a female naval aviator's choice to pursue both a career and a family.

"In addition to increasing their chances of becoming parents, family-building support services can save members valuable time, money and stress along their fertility journey," Shedlin stated.

"Experience across a wide range of industries in the private sector has shown us that offering a managed family-building benefit similar to those being assessed…through the AVIATRIX program has had a positive impact on employee recruitment, retention, productivity and satisfaction," Shedlin explained.

The changes the MFBC is looking to make in supporting military families who face infertility would have a significant impact on everyone, Gustafson added. She explained that when the military delves into a healthcare issue, it innovates and progresses that area of medicine to benefit all. Prosthetic limbs and trauma care are great examples of how the military advanced treatments which have helped everyone.

Changes to infertility services for active personnel and veterans require congressional legislative action.

"We fully believe that if TRICARE covers infertility treatments and provides smart family-building support, it will lead to innovations in technology and fertility services that will benefit every single family," Gustafson concluded.