There are many stories, and almost all of them end the same way.
Laura Flanagan has polycystic ovary syndrome and an irregular period. She’s been trying to conceive with her husband, Adam, a truck driver who’s now in the Army Reserve after deployments in Iraq and Kuwait, for a decade with no luck. Last year, they tried intrauterine insemination (IUI), where sperm is inserted into the uterus during ovulation at a fertility clinic. They’re a one-income household, so Laura’s family covered travel expenses to the Knoxville Fertility Clinic and the $548 for the first round, which failed. They helped at Christmas too, for the second round. It also failed. When the third IUI didn’t take, they decided to weigh their limited options. In vitro fertilisation (IVF) is a logical next step, but it’s too expensive to pay out of pocket.
Erin Bell met her wife through the Air Force four years ago. They are both active duty and in 2021, they decided they wanted a baby. Doing IUI was too pricey. Instead, Bell said they “found sterile syringes literally on Amazon” and used a known donor because Bell, who is based at Royal Air Force Mildenhall in Suffolk, England, said sperm banks there cost about £800. They got pregnant after three months but had to navigate a health care system that largely caters to heterosexual couples.
In 2013, Samantha Shafer married an airman first class making $1,800 a month and spent seven years trying to figure out what was causing their infertility. She had an egg retrieval and two embryo transfers that failed at a cost of about $9,400. “When our first embryo failed, I was like, ‘It’s okay, we have one more chance’ and when the second embryo failed, that was a pain I never thought I’d go through, like, I was on my floor and screaming,” she said. She did another egg retrieval and got two more embryos. In July 2022, she got pregnant but had to terminate the pregnancy at 8 weeks because there was no heartbeat. They relocated to Florida last August on military orders and paid $1,100 to ship their last embryo from Kansas.
Julie Eshelman and her husband, an active-duty serviceman in the Army Reserve, started trying to build their family in 2016 while stationed at Joint Base Lewis-McChord in Washington state. They got on the waitlist at The Madigan Army Medical Center, one of the six military hospitals that offer fertility treatments, but then got called to move to a base in Scottsdale, Arizona. Eshelman waited to get into a local fertility clinic while her husband was deployed. When he returned, their first IUI resulted in a pregnancy, but during another relocation to Chicago, Eshelman miscarried. Two more IUIs had the same results. Finally, in July 2020, they had a successful IVF that cost $20,000 with a military discount.
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“We didn’t go out to eat, we didn’t go to the movies,” she said. “We didn’t really do anything for five years so we could afford to do all these treatments. And that’s not easy.”
If the military broadly covered fertility treatments, even in part, each of these couples could have avoided the financial and emotional hardships of family building that are exacerbated by a life of long deployments, constant relocation, and low pay. But in nearly every case, the military wouldn’t help them—because, by law, it doesn’t have to.
The US military’s health care plan, TRICARE, doesn’t cover IUI or assisted reproductive technologies like IVF unless a service member lost reproductive abilities through a deployment-related injury, a circumstance that is hard to prove, and doesn’t consider the needs of LGBTQ couples. The plan covers some services—such as semen analysis or hormone evaluation—but only when “medically necessary and combined with coital conception.” In other words, you have to prove infertility, defined by the Centers for Disease Control and Prevention as not being able to conceive after having unprotected sex for a year or more, before some coverage might kick in.
In a statement, the Department of Defense wrote that by law, “care is authorized to diagnose and treat an illness or injury of the male or female reproductive system to correct the underlying physical cause of infertility, which would then allow for conception through coitus (i.e., heterosexual intercourse).”
Faced with exorbitant costs, military families seeking assisted reproductive technologies have largely been left to pay their own way, even though about 160,000 military service members struggle with food insecurity. An IVF cycle will usually cost between $12,000 and $14,000 depending on the clinic, but the total bill for the process—perhaps including hormone injections or genetic testing—can exceed $30,000. A newly enlisted service member might receive a $25,000 base salary. To offset costs, some military couples have relied on family money, solicited sperm donors from Facebook, taken out loans, sacrificed vacations, or set up GoFundMe accounts.
It’s impossible to know exactly how many military families need assisted reproductive technologies, but a 2018 study by the Service Women’s Action Network (SWAN) found that 37 percent of female active-duty respondents struggled with infertility, a number three times higher than the national average. This might be explained, in part, by recent findings that show aspects of military lifestyles, like PTSD or deployment length, could affect fertility. A 2020 report by SWAN also noted that military occupations like airplane engineers may lead to toxic chemical exposure, which has been shown to also affect fertility. Responding to a 2021 Blue Star Families survey, 27 percent of military spouses said they experienced family-building challenges.
Now, an internal backlash is growing among rank-and-file families against the very “family values” institution they serve. “If we’re supporting the country, how come they’re not supporting us?” asks Brittany Matta, a military spouse who is positive with BRCA1 and considering IVF so that the gene mutation isn’t passed to her child.
Policy change has long been an uphill battle. In 2019, Representative Rosa DeLauro of Connecticut introduced the Access to Infertility Treatment and Care Act to expand coverage, but it didn’t pass. In 2012, Senator Patty Murray of Washington introduced the Women Veterans and Other Health Care Improvements Act to offer assisted reproductive technology to military spouses of a wounded, ill or injured veteran struggling with infertility. It passed the Democratic-controlled Senate but stalled in the Republican-majority House. These pieces of legislation have gone nowhere, said Ellen Gustafson, a cofounder of the Military Family Building Coalition, because “there is a Republican block.” Gustafson explained that “there is some confusion” between legislators and the pro-life movement, meaning some conservatives liken discarding IVF embryos to abortion.
Now, though, the Army is in the midst of a recruiting crisis. Officials told told the Associated Press in October that it fell short of its goal by 15,000 recruits, or 25 percent. It was the Army’s “most challenging” recruiting year since the all-volunteer force began, in 1973, Army Secretary Christine Wormuth told the AP. The other services also struggled but ultimately met their goals. Part of the challenge, officials explained, is competition from private-sector businesses that offer increased perks.
Nick Perkins, who started Operation Baby Foundation in 2020 with his wife Emma to give fertility grants to military couples, took it one step further. As a former commander who left the military in October 2021 to help finance Emma’s eight rounds of IVF, he witnessed soldiers distracted by family-building struggles. “That can affect readiness,” he said.
This environment has given activists and families hope that they are finally in a good position to leverage their case. “If people are thinking ‘Should I join the military and should I stay?’” said David Kieran, a professor of military history at Columbus State University in Georgia. “The question that orbits is, ‘Will I be able to have the kind of family I want to have?’”
Prior to World War II, enlistees in the US military tended to be very young, single men. During the Civil War, 20 percent of soldiers may have been younger than 18. By some accounts, the Union army had 200,000 boy soldiers, though the American Battlefield Trust notes that the average Union enlistee was 25.8 years old. John Worsencroft, a history professor at Louisiana Tech University, explained that the military attracted young men largely because the pay was bad. “You couldn’t have a family on the amount of money you were getting paid to be a soldier,” he said. The idea that military life was incompatible with family life became even more entrenched after World War I when junior enlistees were prohibited from being married because the military didn’t have resources to house families, he explained.
The landscape changed drastically during the Second World War, though, when the ban was lifted and marriages across the country boomed. A 2017 article in The New York Times noted that out of the 1.8 million American weddings in 1942—an 83 percent increase from a decade prior—two-thirds involved newly enlisted military men. This was also around the time when the military formally allowed women to enlist in 1948 with the signing of the Women’s Armed Services Integration Act.
In 1973, the country adopted an all-volunteer force during the Vietnam War. This meant that the military could no longer draft at all—many young men before 1965 tried to avoid a Vietnam draft by getting married—and had to rely on recruiting instead. In turn, the institution tended to attract careerists and the marital makeup of enlisted members has been skewing toward married, albeit slightly. Research by the RAND Corporation in 2006 found that almost half of enlisted personnel were married then. As of September 2022, the Department of Defense reported that 51.9 percent of active-duty members are married either to a civilian or are in a dual-military marriage.
Throughout the 1980s, family satisfaction became a core focus for purposes of retention. In 1983, John A. Wickham, Jr., then the Army’s new chief of staff, published a white paper titled “The Army Family.” The Hyde Amendment restricting federal funds for abortion had just been passed three years before and Department of Defense officials worried it would limit their ability to recruit and retain women. In his manifesto, Wickham outlined the Army’s “moral and ethical obligation to those who serve and their families.” The Army, Wickham argued, is not an occupation but an institution. As such, the Army should have policies and support in place, including health care, that will make service members feel prioritized and want to stay.
“According to a recent examination of factors affecting retention, when a tug-of-war occurs between a military family and a military organization, the family usually wins,” he wrote, adding that taking “care of our families enhances both retention and readiness.” Wickham and Secretary of the Army John O. Marsh Jr. decided that the following year, 1984, the service’s theme would be the Year of the Army Family.
“That was really the first time in the modern era the Army focused on, ‘What do we need to do to serve families?’” said Kieran, the Columbus State University professor. “And they had to rethink that after the midst of Iraq and Afghanistan. Families were having a lot of challenges and mental health struggles. It’s been a constant evolution.”
TRICARE launched in 1993 following this pivot to a family-first mentality, which also coincided with the rise of the Christian right and the idea that the “traditional family” was under assault, according to Worsencroft.
Previously, there had been federal recognition of military medical benefits through a program created in the 1960s called the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), which expanded coverage for family members, dependents, and retirees. TRICARE was similar to CHAMPUS but offered more comprehensive benefits like an HMO, giving the Department of Defense the ability to contract with health care providers and dip its toe into the concept of managed care. Today, TRICARE has different plans, both for managed and self-managed care.
According to the law, TRICARE can only cover services that are “medically necessary.” Bryce Mendez, an analyst of defense health care policy for the Congressional Research Service, said that this clause is driving today’s debate over fertility treatments. “The bar for accepting what’s covered and what’s not is fairly high,” he explained. Right now, the Defense Department has not deemed what it calls “noncoital” fertility treatments to be medically necessary, a stance that many see as misguided and false.
“A lot of the times people have real medical conditions that are stopping them from getting pregnant,” said Elise Kenyon, a military spouse who had a daughter through IVF. “And TRICARE doesn’t see it that way.”
The farthest step forward so far has been a program enacted in the 2008 National Defense Authorization Act that covers IVF if a soldier can no longer conceive because of a deployment-related injury. (The move came as soldiers in Iraq and Afghanistan were being wounded in record numbers.) But according to Mendez, there has been no move to reevaluate the “medically necessary” clause as it pertains to fertility treatments.
“That is something [the Pentagon] can do,” said Mendez. “Have they done it? I’m not aware of that.”
In its statement, the Department of Defense wrote, “While the Department is sympathetic to family building challenges our service members and their families may experience, expansion of existing TRICARE coverage to include ART services would require additional statutory authority and funding to provide these services.”
More and more private corporations are now offering assisted reproductive coverage for employees. Starbucks, for instance, covers $25,000 for IVF. A 2017 TechCrunch article noted that tech companies like Apple and Google “paved the way for fertility perks” before other companies soon followed suit. The fact that the military doesn’t cover IVF has left today’s families disheartened.
“How is Starbucks covering IVF,” asked Crystal Simpson, who is married to an Army major and was able to get some IVF coverage at the US military’s Walter Reed hospital after paying mostly out of pocket through the University of Kansas hospital system, “but the US military won’t?”
Ellen Gustafson was on her book tour for We the Eaters: If We Change Dinner, We Can Change the World, published in 2014, during the early weeks of her pregnancy. Her husband, Michael Campbell, an active-duty serviceman in the Navy, had been home and they were able to conceive. But Gustafson, the cofounder of FEED, a purse and bag retailer whose proceeds go toward ending childhood hunger, “had this family issue that goes back five generations where male babies would mysteriously die in utero towards the end of the second trimester.” Her mother had four such losses. In the hospital, Gustafson gave birth to a stillborn.
The doctors told her to try IVF so she could select a female embryo. “I called TRICARE’s phone number and said, ‘My stillborn cost you $35,000. I’m either just going to do that again potentially, by trying to get naturally pregnant, or you could afford to give me a couple rounds of IVF,’” she said. “And the blanket answer was no—and it made me angry.”
Gustafson went through six rounds of IVF and $120,000, though she admits this price tag was a lesser blow for her and Michael than it may be for other military families. During the process, she became naturally pregnant with a girl, who she carried to term, and then used two of her embryos and had twin boys. But the whole situation had angered her.
Gustafson started the Military Family Building Coalition in 2020 with another Navy spouse, Katy Bell Hendrickson. So far, it has supported the Veteran Families Health Services Act of 2021, a Senate bill introduced again by Murray that calls on the Department of Defense and the Department of Veteran Affairs to extend fertility treatments like IVF to veterans, which wouldn’t necessarily help queer veterans because the bill defines a covered member as “a former or current member of the Armed Forces who has an infertility condition unless it is demonstrable that the individual was completely infertile prior to serving in the Armed Forces.”
(Murray did not respond directly to questions about the limitations in this legislation, but said in a statement, “Veterans across the country already face so many challenges after coming home from war—starting a family shouldn’t be one of them. That’s why I introduced this bill to help make sure service members and veterans can get the reproductive care they deserve. I know how deeply important this is to millions of veterans who’ve made tremendous sacrifices for our country, so I’m focused on getting this across the finish line.”)
The coalition has also partnered with fertility clinics through WINFertility and Legacy and was involved in inserting a 1,000-person pilot program for cryopreservation and storage in the National Defense Authorization Act for Fiscal Year 2023, which passed the House.
“These are people who America waves the flag [for]…and are suffering in silence and cannot have the children they want,” said Gustafson of military families, “and I thought, ‘This has to change.’”
A quieter coalition of spouses is also banding together around their pain. In online chat rooms and bases around the country, regular rank-and-file families are sharing their stories with one another to try to blunt the agony of infertility and navigating TRICARE.
Bethany Cereo doesn’t mind that the fight to change health care coverage in the military is largely being spearheaded by heterosexual couples and framed in terms of infertility, which not all LGBTQ couples experience even though they often rely on assisted reproductive technologies nonetheless.
“So much has been on the backs of queer people to fight, fight, fight,” she said. “Like, let’s let the heteros take one.”
When I visited her in Albany, N.Y., in early December, Cereo was seven days past ovulation (or DPO, as she’d learned to say). She lives in a single-family house with a pool and a small front yard. Her spouse, an active duty trans man in the Army, relocated to West Virginia to be with his mother while she was sick, so Cereo has the company of their two rescue dogs, Beesly (named for Pam on The Office) and George (as in Lucas, the Star Wars creator). She’s a lawyer for Legal Aid, working in domestic violence and family law. For extra cash, she sometimes delivers groceries for Instacart and used to drive for Uber and Lyft during the holidays.
In March 2022, right after I asked an admin of the LGBTQ Enlisted Military/Veterans Facebook group to post on my behalf, Cereo reached out to tell me about her thoughts on TRICARE and added that she was six weeks pregnant after self-inseminating with a $99 Mosie syringe. She later miscarried at 12 weeks. When I visited her, she and her spouse were trying again with a donor friend in Rhode Island (with self-insemination, there’s a chance that an unsterilized syringe could cause bacteria to enter the vagina, but experts have said the risk is low).
Like Cereo, some queer couples have gone the more DIY route, while others have navigated discriminatory practices of TRICARE and reproductive health care more generally. Bell, the active-duty service member in England, said that when she and her wife went to the US military hospital RAF Lakenheath in Suffolk, the paperwork still said “mother” and “father.” “We cross it out and say ‘parent,’” said Bell.
Carmen Crow, a comedian married to a female nuclear Navy engineer, tells a joke during her stand-up routine about once responding to the question on fertility treatment paperwork about her fertility defect by writing, “I’m gay.” And Caitlyn McDonald, whose wife is a maintenance control officer and was recently deployed in Germany during the Russia-Ukraine war, said her primary care physician diagnosed her with “chosen infertility.”
Like many military spouses who begin looking into assisted reproductive options, Cereo called up her health care provider, Martin’s Point, a not-for-profit health organization in Maine that offers TRICARE coverage around the Northeast. On the phone, she was told that the military plan only covered procedures that support “natural conception.” Cereo took this to mean they only support heterosexual couples.
“I was like ‘What are you trying to say?’” she said. “’That we’re unnatural because we can’t conceive of a child naturally?’”
There are some happy stories, too. Toward the end of my visit, Cereo wanted to show me something. Laid out on the kitchen table were six Lenormand cards in two neat rows of three. She had pulled three of the four “people” cards from the top of the deck, which she thinks resemble her spouse, herself, and the donor. Intrigued, she pulled three more cards: the letter, the rider, and the stork. Altogether, that pairing could mean a birth announcement is on the way. Finally, she pulled a card from the bottom of the deck. The baby.
“These cards are really good to me,” she said.
Cereo planned to self-inseminate for a year before she looked towards other options, but the prospect of IVF felt daunting and financially out of reach.
Then, in late January, she texted me. The cards had been good to her. She was 10 weeks pregnant.
“Excited,” she wrote, “to get into the calmer waters of the second trimester.”