As with all wars, the effects of recent conflicts on the nation’s veterans have taken their toll in many ways. One of the consequences of the widespread use of improvised explosive devices (IEDs) and the traumatic injuries they cause can be infertility. As noted in the Federal Register, “The Joint Theater Trauma Registry (JTTR) reflects the most common single cause of battle injuries is explosive devices (36.3%). Such trauma frequently results in genitourinary injury. … This increasingly common trauma can have catastrophic reproductive results.”

While the medical benefits package for veterans has included numerous diagnostic and treatment services for infertility, the Department of Veterans Affairs (VA) has been prohibited since the late 1990s from including among those benefits in vitro fertilization (IVF), a common, medically accepted procedure involving manual fertilization of eggs by sperm in a lab, with a resulting embryo being implanted into the uterus.

But now, because of the yearslong efforts of lawmakers, advocacy groups, and veterans and their families, thousands of wounded veterans do have access to that additional means to start or expand their families.

Specifically, an interim final rule authorizes the VA to provide IVF treatment to veterans with a service-connected disability that results in the inability of the veteran to procreate without the use of fertility treatment.

The rule also allows the VA to offer fertility counseling and treatment using assisted reproductive technologies (ART), including IVF, to a spouse of a veteran whose service-connected disability results in infertility. In both cases, the new rule marks the first approval for the treatments, and offers these veterans and families another alternative and further hope in fulfilling their desire to have children.

These changes became effective in January as a result of legislation – the Continuing Appropriations and Military Construction, Veterans Affairs, and Related Agencies Appropriations Act, 2017, and Zika Response and Preparedness Act – passed by Congress last September. Because of the law, explained Patricia Hayes, Ph.D., chief consultant for the Women Veterans Health Strategic Health Care Group in the VA Office of Patient Care Services, “VA drafted this interim final rule and published it in the Federal Register on Jan. 19, adding this new section to the VA law in the Code of Federal Regulations.”

While advocates praised the law’s passage, Hayes pointed out that there is an end date to the rule. “It was passed under an appropriations law, and that law expires at the end of September 2018,” she said. “We are dependent on Congress to consider whether to renew this benefit by passing additional legislation.”

Sen. Patty Murray, D-Wash., has been one of the staunchest promoters of ending the ban on covering IVF in the VA, and her amendment to the bill during a committee markup is what now allows it. But because the bill does not permanently repeal the IVF ban, she has expressed her determination to push for its full repeal.

In a written response to Veterans Affairs & Military Medicine Outlook, Murray asserted, “As a nation, we promise our veterans we will take care of them after their service is over, no matter what. Yet for more than 20 years, because of politicians’ personal beliefs, the VA has been unable to help wounded veterans and their spouses fulfill the dream of having a family. I think this is wrong, which is why I have fought relentlessly for legislation that ensures fertility services for veterans who were injured while defending our country.

“But our work is not over,” Murray continued. “I will keep working to repeal VA’s outdated ban once and for all. This is the least our country can do for the men and women who sacrificed so much to serve our country.”

 

Continuity of care

While the VA did not cover IVF until recently, the Department of Defense (DOD) has provided IVF treatment to eligible service members on active duty. But when veterans left service, they were no longer eligible for IVF under the VA. The interim final rule notes that “most of the ART evaluation and treatment modalities offered by VA are consistent with DoD policy guidance. The exception is IVF. DoD offers IVF to servicemembers who have sustained serious or severe illness/injury while on active duty that led to the loss of their natural procreative ability, while IVF is excluded from VA’s medical benefits package …”

With these changes, the interim final rule states, “This rulemaking will ensure that covered veterans leaving service at this time, and their spouses, will experience continuity of care when transferring from health care provided by DoD to that provided by VA, with no difference in the level or types of available ART.”

Hayes elaborated on the importance of the ability to transfer care from one entity to the other. “One of the things we recognize is that when someone is seriously wounded in terrible IED injuries and blasts, they have a period of time that they may be discharged from active duty, but they may not be fully healed and back to a situation in which they’re thinking about activity or family life or having children,” she said. “They’re getting their lives back together. Many of them have been out of active duty for some time. They were eligible for [IVF] while they were on active duty, and so for us, it’s really changed things to be able to now say to those veterans, ‘OK, you took some time [to recuperate], but VA can now offer you this service.’”

 

IVF and other fertility treatments

While the Code of Federal Regulations explicitly excluded IVF from the VA medical benefits package until earlier this year, Hayes said, “I think some people don’t recognize that VA for quite some time has done infertility evaluations and treatment, including things like ovarian stimulation for certain conditions, sperm retrieval, freezing of sperm for veterans who have malignant conditions and cancer treatment, freezing of the ovum, and artificial insemination. We were able to do many things; we just weren’t allowed to do the in vitro fertilization part of infertility treatment.”

Other treatments VA has long provided include infertility counseling, laboratory blood testing, semen analysis, genetic counseling and testing, ultrasound, reversal of tubal ligation and vasectomy, hormonal therapies, surgical correction of structural pathology, and others.

These treatments have been for veterans only, and Hayes said that part of the former difficulty regarding infertility treatment was that VA is only allowed to treat veterans, not families or spouses. “When you get into things like fertility, obviously treatment in the past has been difficult because fertility is really a diagnosis of a couple trying to become parents, become pregnant,” she said. A key difference now, regarding infertility treatment only, is that “the new law and the new regulation allow us to treat a specific group of veterans and their legal spouses.”

Hayes explained how a veteran would begin the process. “If they haven’t been evaluated for infertility, then we would start with that,” she said. “Men would go to a urologist in the VA, or in the community if distance is an issue, and a woman would go to a gynecologist. If they’ve already been in a process where they’ve been evaluated somewhere else, it’s already been determined what they need, then they could bring their records in to the VA and be referred to a reproductive medicine clinic to continue their treatment.”

If IVF is indicated, Hayes reiterated that the process starts with the veteran, who, to be eligible, must be legally married and have a service-related condition that results in the inability to have children without fertility treatment. The interim final rule specifies what this means: “for a male veteran, a service-connected injury or illness that prevents the successful delivery of sperm to an egg; and, for a female veteran with ovarian function and a patent uterine cavity, a service-connected injury or illness that prevents the egg from being successfully fertilized by a sperm.”

These conditions could result from not only genitourinary injury in men and women, but also other combat trauma such as brain or spinal cord injury. Hayes said, “More often for women it’s an illness, a PID [pelvic inflammatory disease], a fallopian tube obstruction – something that occurred while they were in the military, it is documented, and they are rated by the VA as having a service-connected disability.”

Without specifying an exact number of veterans who have begun the process under the new law, Hayes said, “We projected that the total group was going to be about 450 a year, based on the number of people we know have these rated conditions,” with a total pool of about 4,500 veterans.

Hayes added that instead of having a list of IVF-eligible conditions, “We go on a case-by-case basis to determine what the infertility situation is, what’s causing the infertility, and then look to their service-connected graded conditions to see if there’s something that relates to their infertility.”

Describing where IVF services are delivered, Hayes said, “We provide a lot of fertility evaluation, however, reproductive endocrinology and actual IVF is not provided inside of VA facilities. We don’t have the technology for this, for what is actually a relatively small population. We are using contracts with outside providers in the veterans’ community area.”

In the IVF process, “they can go through a number of cycles to try to be effective. If it’s not effective the first time, we can have up to three completed cycles.” Hayes explained. One IVF cycle takes about two weeks.

“Hopefully, [the process] goes on to a successful pregnancy. What we know from the science is that IVF can be about 80 percent successful by the time you’ve gone through three attempts, three cycles,” she said.

 

Community Resources

“We want veterans to start with us first, and see what they’re eligible for and how we might be able to help them out,” Hayes said. But, while not endorsing any particular organization, she identified other resources for those who don’t qualify for this VA benefit; for example, if they don’t have a service-connected injury, or they’re not legally married.

A representative sample of these resources for infertility services include local and national veterans’ organizations like the Wounded Warrior Project; financial assistance programs for fertility products through Ferring Pharmaceuticals and EMD Serono Inc.; discounted IVF services through members of the American Society for Reproductive Medicine; and the infertility advocacy group RESOLVE: The National Infertility Association.

Another example of organization support is the Bob Woodruff Foundation (BWF), which established an IVF fund offering financial assistance to help veterans cover unreimbursed costs of IVF treatments. Barbara Lau, IVF fund administrator, said the organization’s commitment to this endeavor strengthened following a 2014 BWF-hosted conference on intimacy after serious injury. “It was a great big shock, I think to many people, to discover that, at the time, VA was prohibited by law from providing IVF services,” she said.

“So we did two things. We decided to put money toward this and offer eligible applicants $5,000 toward unreimbursed IVF treatment costs. It’s not going to cover everything by a long shot, but for many of them, it’s a big help,” Lau said.

For more information about infertility services including IVF, veterans are urged to contact their local VA facility. Alternately, they can call the Women Veterans Call Center at 1-855-VA-WOMEN or 1-855-829-6636. This is the correct resource for men and women to obtain information or a referral to an appropriate VA contact.

She continued, “Simultaneously with that, we joined hands with 14 other organizations. We didn’t lobby because we can’t, but we advocated with members of Congress that they really needed to support the bill that was coming up.”

Lau said the group of 15 organizations “advocated very strongly that if these men and women can be supported [with IVF] while they are on active duty, let us enable them to be supported once they are medically retired and veterans. And lo and behold, it passed.”

Emphasizing the commitment of the BWF, Lau said, “If you look at our tagline underneath our logo, it says, ‘Investing in the next chapter for our veterans.’ What could be more life-affirming, more normal, than to want to have children?”

Hayes reinforced that message. “When you think about these very seriously injured veterans who just want to be able to have a family, there is more of a feeling that this [ruling] allows us to really help them complete their quality of life and their family life,” she said.

“I think that this is part of the sense of what a tremendous sacrifice these individuals have given for the country,” Hayes continued. “I talk with them, and it’s always touching to hear about the horrendous things they’ve been through and how far they’ve come, and their intense desire to have a full life; and that life includes having children.

“For me, it just fulfills that sense that we owe them for everything they’ve done,” concluded Hayes. “If these folks aren’t deserving, I don’t know who is, when we think about the ultimate sacrifices that veterans give to keep us safe. I think that’s the message about who these folks are, and how important it is to them for us to be able to help them out.”