SART Fertility Experts - Military Families and Fertility

Yeah, here we are, we're doing a discussion today with Dr. Micah Hill. Dr. Hill has just concluded an illustrious career in the military. I'll let him tell you a little bit about that and where he's served and what he's done.

But we're focusing today on special groups that receive treatments for fertility. And today we're going to be focusing on the military families and what they might need that might be a little bit different than others. So first I should say, retired Colonel Hill, thank you so much for your service.

Can you tell us a little bit about your experience in the military, how long you've been serving, the type of people you've been serving, and what that's looked like over the last 20 plus years? Sure, Tim. Thanks for having me for this wonderful conversation and thank you for your service as well as we talk about the military. We appreciate your service.

I've just ended 21 years active duty in the U.S. Army. I joined the Army to pay for medical school for under the HBSP program and did my residency in Hawaii and then served at Fort Campbell, Kentucky. And then I've been at Walter Reed in the DC area for the last 15 years for the remainder of my career, both at old Walter Reed and then at the new Walter Reed National Military Medical Center.

So taking care of our active duty sailors, soldiers, and airmen and their families for that time. So we take care of the full gamut of military couples that need reproductive health care, single soldiers, same sex couples, anyone who's currently serving and has a diagnosis of infertility or any other reproductive health disorder. Excellent.

Thank you. Well, again, thanks for your service. We really appreciate it.

I know you've trained and helped many, many people along the way. So a lot of people out there are very grateful for your service. Let's talk a little bit about the military and how would this population differ from others? Is it about the same as other populations within our society or are there some unique features of this group? The military population is interesting in that unlike many fertility clinics, our population in the military really represents the US population.

So we have fairly similar demographics and access to care to what we see from the general US population. So we don't have the same access to care issues that are sometimes seen in other populations within the fertility spectrum. Our population obviously is active duty and we see about the same levels of infertility within the military, if not even a little bit higher, but it's hard to actually access that data.

But some of it might be higher just because of the exposures that our service members are seeing, both from chemicals, radiation, vibrations, our pilots flying and some of the exposures that they get from that. So there's some things we think that might actually be a little bit higher in the military population, but actually getting to that data is sometimes hard to access. So I would say overall, our population is fairly similar and very representative of the US population overall and those that are serving our country.

Excellent. So if I was a service member now, how would you advise me? When should I seek treatment? How should I seek treatment? What resources are available? Yeah, that's a great question. And I just want to put a caveat to the answer I just gave.

We do sometimes see infertility in the military that's simply due to the deployment cadence or the operational cadence. I've had many people, especially surgeons and people who are in armored brigades and those sorts of things who are deploying at a high frequency level that have been infertile, not from the standard definition, but just because they haven't been around their partner or had the opportunity to procreate. Sometimes this has gone for over three, four or five years just because they're constantly deployed.

And so we do see people that reach out to us because of that. Maybe many people who are active duty or dependents with benefits don't know that the diagnosis and evaluation for infertility is fully covered in the military. So if you've had 12 months of trying to get pregnant and have not been able to, if you're over the age of 35 and it's been six months, or if you're just over the age of 40, so if you meet the SART and ASRM definition of infertility, then certainly we can see you and take care of you and that evaluation will be fully covered.

As far as the actual benefits of getting the treatment, we'll probably get to that in a minute. But if you're trying to get pregnant and haven't been able to, or if you even just think you want to get pregnant and want preconception counseling, that's fully covered in the military and you should just reach out to your primary care specialist and get a referral to either OBGYN or your infertility specialist. Excellent.

Well, thanks. Tell me a little about this. So I remember when I served, and this is dating me, it was back in the 90s and early 2000s.

We had a younger population than we typically see I know here in Houston. Is that the case or have they delayed childbearing just like the rest of our U.S. population? It probably depends on where you're serving in the military. As an REI specialist, since I've been in the D.C. area, I tend to see an older population.

I see a lot of senior enlisted and senior officers who have delayed childbearing for their purpose of their career. So the patients that I'm seeing are often in their late 30s, early 40s, sometimes even mid-40s because of the service and the sacrifice that they've given to our country. That might vary if you're stationed in Hawaii or the Midwest.

It might be a little bit of a different population. So probably depends upon where you're serving. Okay, good.

So it sounds like it probably mirrors the demographics of the areas around which this is. Yeah, I think that's right, yeah. So let's talk a little bit about available services.

So you kind of mentioned that the basic workup is kind of available to all. Is that the case? Yeah, the basic workup and any sort of evaluation is fully covered for all military people. And let's say they do need some treatment.

Let's say, first let's talk about lower level treatments like maybe intrauterine insemination, ovulation induction. Are those things typically covered in the military? Yeah, it's a great question. So this is where it gets a little bit tricky, Tim.

So under TRICARE, and just to clarify, when we talk about TRICARE, we're talking about military healthcare insurance that is outside of military treatment facilities. So this is essentially the military purchasing your healthcare for you from a civilian provider. By congressional law or mandate, TRICARE only covers coital services.

So that essentially means you have to have fallopian tubes that are working, a uterus that is functional. You have to have a male partner who has sperm parameters and you're able to get pregnant using coitus or sex. So that essentially limits TRICARE or purchased healthcare for military couples to ovulation induction.

So people like say PCOS, where they're not ovulating and they have a male partner whose sperm is normal, that would be covered under TRICARE. But anything that goes beyond that, once we get to intrauterine insemination, that's no longer coital because we're taking obviously the sperm and washing it and prepping it and then injecting it to the uterus. So that would not be covered, nor with more advanced services like IVF.

Now the caveat to all of this is that that's TRICARE. So that's only what is being purchased from a civilian provider for you. So you're not being seen at a military treatment facility.

If you're being seen at a military treatment facility, then it's completely up to the commander of that hospital at that treatment facility what they will cover. Many of them, if they have OBGYNs there, will cover intrauterine insemination. And I used to do some of those at Fort Campbell, Kentucky, because the lab was willing to let us spin it down and do those services.

But at other places, you may not have an OBGYN or a lab or the hospital commander that's willing to do that. So it's going to be very dependent for non-coital services as far as where you're located. Is there a way, let's say I'm a serviceman serving in Minot in the Dakotas.

Yeah. How would I know if these services are available or if they're not available? Yeah. It would be hard to know.

You would have to see it. You'd have to contact your local OBGYN there and get a referral to them and see if they offer it. If it's not available at your military base, you could look on the Resolve website.

Resolve has a list of IVF and fertility clinics around the country that offer special programs for the military, often at very significant discounts, and see if you have access to your local civilian infertility. But if you're doing that and it's non-coital services, that won't be covered by TRICARE. So even with the discount, sometimes that can be very limiting, especially for our junior enlisted and junior officers whose income might not be enough for them to afford fertility coverage, unfortunately.

Got you. So there's not a directory of military bases that offer IUI. You'd have to ask individually.

Is that correct? That is correct. And unfortunately, that's something that changes frequently because really you need an OBGYN at that base that's interested and willing to do that, as well as a hospital commander who's supporting that and willing to pay for it, as well as the laboratory who's willing to spin it down and provide the sperm washing and preparation. So all of those things are always evolving.

And if we made a directory today, it'd be out of date in a year from now. So it sounds like a very fluid situation. Okay.

Well, let's go into, I know that IVF is offered at some of the centers. So let's speak to that. Maybe if you could address both Army, Navy, Air Force, Marines, Coast Guard, if that's the case, all services, just so we know about that.

Yeah. So we do have IVF currently at eight centers in the US, including Hawaii. And it's sort of an interesting story of how we got there.

In order to have OBGYN residency programs, which the military strongly supports, and we have a very robust service of OBGYNs who deploy all over the globe to support our soldiers, you have to have all the subspecialties within OBGYN. So you need gynecology, maternal fetal medicine, urogynecology, and you need REIs. So we do have REIs present at all of our eight training facilities in the United States.

And because we have that, if you're going to have REIs, you want to be able to support them doing the full spectrum of what they're trained to do, which includes IVF. So just like a GYN oncologist, wherever they are, they need to be doing surgery and radiation and chemotherapy, our REIs need to be doing surgery and in vitro fertilization. So currently that is supported at those eight sites.

Because these are at military treatment sites, these aren't under TRICARE law. So we can do non-coital services as long as the hospital commanders support us. And we've been fortunate that at all eight of these sites, they've consistently done that.

So currently on the East Coast, that would be in DC, Walter Reed, that would be at Norfolk, Portsmouth, which is just starting to offer IVF services this year, Fort Bragg. In the Midwest, that would be at Wright-Patterson in Ohio, and then at San Antonio, where you served, Combined Air Force Army Base. On the West Coast, we would have Madigan in Seattle and Tacoma area, and then we'd have Navy San Diego.

And then way out in the Pacific in Hawaii, we also do IVF there. So those are the eight sites where you currently can get IVF. And for example, at Walter Reed, about half of our population is in the Maryland, DC, Virginia area, but about half of our population comes from outside of town, including Europe.

And these people often come out to us for a couple of weeks to be able to do IVF. So those are the eight sites where you can get IVF if you're active duty currently. So how does one arrange that if one is in Europe or stationed somewhere else to get to one of these sites? How would that work? Yeah, all we need is a referral.

So you can see if you're in Italy at a base there, you can see your family practice doctor, your internal medicine doctor, whoever your primary care specialist is, and just ask for a referral to Walter Reed. We'll get that referral and we'll send you information. We try to do all of the workup and as much of the initial discussion by telehealth.

And so you don't have to come over for any of that. We should be able to get everything done. If you need surgery or anything before for the uterus or for the male or the female, we can usually do that where you're at.

And then we can set you up to do the IVF cycle. So you can come to Walter Reed just for the two weeks to do IVF. Since I was active duty, we've come a long way.

When I started, there were no policies in the Army, Navy, or Air Force supporting IVF. And currently we have policies in all three of those services that support IVF and actually grant commanders the ability to let those service members come and travel, often not having to take leave and sometimes even being funded by their service to come, as well as provisions to sort of protect those patients from having to do physical fitness test while their ovaries are stimulated. Obviously as the ovaries get stimulated and big, we don't want people doing the hardcore military exercises, physical fitness things that they might normally do that might endanger the ovaries.

So all three services, those three primary services now have policies that help cover and support their ability to travel and be protected while they're getting fertility care. Well, that's excellent. That's fantastic.

It seems like it's continued to progress through the years. Yeah, it's been baby steps. We've been fighting dozens of small battles, one at a time, trying to advance the care for our service members.

And fortunately, we've won a lot of them. I would like to get us to the point where we have full fertility coverage and IVF coverage for every active duty person, but we're not quite there yet. Yeah.

Is that something that you think is likely in the future? I know this is speculation now, but what's the general feeling in the military about further services? I mean, here in Houston, for example, we're seeing a much, much higher percentage of the population with full coverage for IVF now. Is that the general feeling in the military community as well? There's been a lot of impetus and initiatives to try to get fertility coverage. The Navy a few years ago tried to launch something that would be essentially egg freezing and sperm freezing for high-performing people that were committing to serving a full career.

But all of these things cost money. And unfortunately, that never got off the ground. It's funny because I mentioned that TRICARE is a congressional provision that limits TRICARE coverage to coital services.

I've been involved in half a dozen congressional inquiries over my career. So while I was on active duty, I was not allowed to advocate to Congress. But if Congress asked the military for an answer, we have to give it.

And so I was involved in half a dozen of those responses. And it was always interesting because the senators or congressional people that were asking us for this information didn't realize that it was their own provision that was inhibiting us in the military for providing this coverage. And so really what I think it will take is a law being passed, getting through Congress, and then being signed by the president that authorizes and even mandates that fertility coverage is provided.

And Tim, you're much more savvy with insurances than I am. But when most big insurances have added IVF care, it really doesn't drive up premiums. It's pennies on the dollar for what it costs when you're talking about a big health care system to add IVF coverage.

So I hope at some point that we'll do the right thing. We certainly, as you alluded to in Houston and in many big cities, you see a lot of these companies that are competing for our top people, our top officers, our top senior enlisted trying to recruit them to their companies are offering these benefits. And I think it's time that the U.S. military sort of caught up and got into this 21st century with offering these benefits.

Certainly the people that are serving our country deserve them. I think we would all agree on that. Hear, hear.

Totally agree with that. That's, I mean, of all people to be given these benefits, you'd think that those that are risking their life, life and limbs for us should be given those benefits. Yeah.

Well, we've talked a little bit more, we've talked about more traditional services. How about special groups within the military, LGBTQ services, anything like that? I know this has evolved over the years in the military. Can you speak to that a little bit? Yeah, that's a great question.

So I'll start with service members who have injuries. So if you're a category two or three service member, essentially this would be anyone with a war injury or training injury that has threatened your fertility. And this would include cancer patients.

So this would include oncofertility. If you're a category two or three injured and that affects your fertility or a medical condition that affects your fertility, then IVF is completely covered. So that is completely covered and paid for by the military under those conditions.

Now, unfortunately, until just this year, that required you to be heterosexually married in order to have that benefit. So it could be the partner or the service member, but you had to heterosexually married. We did in the last answer to Congress about fertility services in the military, the last congressional inquiry, the Pentagon did change that policy.

And so I'm happy to say that as of March 8th this year, if you're same sex couple or a single soldier, as long as you have a category two or three medical condition, IVF is fully covered. So the military will cover up to six egg retrievals and up to three full IVF cycles of those frozen embryo transfers in order to get pregnant. So there is no longer that discrimination.

We did several years ago, almost a decade ago, have varying policies throughout the MTFs, military treatment facilities, as far as who would be treated. And at some of the more conservative sites, there were limitations on single soldiers and LGBTQ soldiers being treated. And about a decade ago, we had an initiative that standardized care across all of the military treatment facilities and aligned ourselves with ASRM policy, which obviously would say that we should treat all people the same regardless of their sexual orientation, their gender, any of those.

So for the last decade, care has been offered at all of these sites, regardless of your status on LGBTQ or heterosexual or married. If you need infertility services, we're here for you and we want to be able to provide those. Excellent.

Well, that sounds like a big change from don't ask, don't tell from the years past. Indeed. Yeah.

How about, let's see, any other aspects that we haven't touched on that you think would be important for our listeners out here in the military community? Yeah, I think as we, you know, now that I'm retired, I can actually advocate on the public side. I would just encourage anyone who feels like these are important issues to reach out to your senator, your congresspeople, and encourage them to, at a congressional level, mandate that IVF be covered and all fertility services be covered for our active duty members. I think that's the most important thing.

I don't think the military is going to make that change on their own without congressional action, without the government sort of authorizing and mandating that that happens. So I've been alluding to multiple tiny battles we've been fighting. That's really the big way we win sort of this war from the military analogy that we get the service that our service members all deserve.

So I would just encourage anyone who feels that this is an important issue to reach out locally and advocate that Congress changes this policy. Excellent. Well, hey, Micah, thank you so much for all your knowledge and insight on this topic.

I know many of our service members are going to be very, very happy to have the chance to listen to this and kind of understand how to navigate through the system. And it sounds like things are getting better and better. So thank you so much.

Thank you for having me, Tim. It was a pleasure. All right.

Have a great day.