WHY THE PENTAGON HAS NO FERTILITY BUREAU

This book is written by someone who has never worked at the Pentagon. Compared to me, most of my readers (or their partners) will have a much closer connection to the U.S. military system. It’s a very large organization and a lot of important things get done there. It’s fair to say that every aspect of the U.S. Defense Department is, directly or indirectly, in the business of protecting and defending the United States of America.

Those are some very special jobs. But in purely medical terms, the people who work in our military are rather like anybody else. Unfortunately if you’re in the military and find yourself needing help in the area of assisted fertility, it’s unlikely you will find a very sympathetic ear there.

But why is that?

For the past few years, this issue has interested me very much. Sure, fertility treatments cost money and every institution must prioritize how budget resources get allocated. Currently, the allotment specified for advanced fertility treatments for active duty or retired U. S. military personnel is zero.

Sadly, this means that our military service personnel who need access to the advanced reproductive technologies to grow their own family is something that is simply not registering at the highest levels of the U.S. government. Against that bleak background, however, there are a few reasons to be hopeful for a brighter tomorrow. In the following chapters, this book highlights some of those stories.

One example of how things have changed for the better is the way the U.S. military protects service members against the ravages of IED blasts. Sometimes little things can make a big difference. And by funding new ballistic underwear for our fighters (see p.190), the Defense Department was able to reduce the number of catastrophic genital injuries by around 30% between 2010 and 2011 [Carter, 2014]. But as discussed in more detail later, there are many young military personnel who weren’t so lucky—they still need our help. These are the patients I see in my clinic every week.

I’ve spoken about fertility with a lot of active duty service members, and whether it’s an enlisted person or an officer talking to me, the consistency of their observations is remarkable.

I’m told that the reason there’s no “Fertility Bureau” at the Pentagon is that the U.S. military actually has little interest in our armed forces members getting pregnant. But how big of a problem are we talking about? Less than 15% of U.S. adults overall are veterans, and not all of them (thankfully) are concerned about fertility problems. I like to use this statistic because it helps frame the magnitude of the problem more realistically. The Pentagon can’t dismiss the problem as “too big of a cost burden” if only a small percentage of military personnel truly need medical help with assisted fertility treatment.

So if it’s relatively inexpensive (in Defense budget terms), then why can’t the standard health plan for our active duty military staff and Veterans include the option for fertility treatments? Is the system really against helping our people achieve a pregnancy?

It’s easy to see that from the viewpoint of top military leadership, pregnancy is a sometimes unavoidable—but always unwelcome—disruption. If you get pregnant in the military, nothing really stays the same. It might even mean separation (discharge) from the service. At the very least, it is a status re-classification that will mean everybody else’s duty rotation has to be modified to accommodate your “situation.”

While the civilian medical system is certainly far from perfect (and there are recognized bright spots within the V.A. health system), the current conditions inside our military health networks are important to know about.

Take for example the sad case of a U.S. soldier’s wife, Jessica Zeppa. She was five months pregnant and visited Reynolds Army Community Hospital (Ft. Sill, Oklahoma) multiple times for fever, belly pain, weakness, and not being able to swallow. The Reynolds Hospital is not a V.A. facility, but rather is operated by the U.S Department of Defense.

Her husband was on active duty in Afghanistan. She needed serious medical help but wasn’t admitted to the hospital until her fourth time trying to get in. Mrs. Zeppa was finally allowed to stay after she was brought in by an ambulance—but she was later airlifted to a private sector (civilian) hospital. There, despite heroic efforts to save her and her baby, she suffered a miscarriage and died on Oct. 22, 2010, of complications from severe sepsis, an infection which had spread all over her body [LaFraniere & Lehren, 2014].

Because this pregnant patient was young and otherwise healthy, experts noted later that she (and maybe her unborn baby, too) probably would have survived if only the medical staff at the Army hospital had properly diagnosed and treated her. And we’re not talking about ancient history here; this just happened in 2010.

The matter of Jessica Zeppa eventually ended with a $1.25 million malpractice settlement. Remarkably, her death apparently never triggered any patient-safety examination by the institutions involved in her care [LaFraniere & Lehren, 2014]. While this tragic event was brought to the attention of the general public this summer by a major newspaper with a worldwide readership, the service members with an interest in fertility and pregnancy tell me that this horrific story is just the “tip of the iceberg.”

And over in the V.A., the scale of federal mismanagement and dysfunction was such a problem that a Cabinet secretary recently handed in his resignation. At my office, patients have mentioned that the scope of the problem will never be known until there is better tracking and reporting of how care is delivered by all military medical facilities. Regrettably, while our brave fighters are in harm’s way on distant battlefields, bureaucrats back home argue over who should monitor the hospitals that take care of the injured when they return.

The New York Times reported on this very problem in an extensive investigation, where these turf battles turn into more land-mines waiting for our wounded warriors once they get home. Apparently, it boils down to disagreements between officials in the Pentagon and in the individual armed service branches. Sadly, in such a politicized system, data on patient safety itself is viewed as a weapon [LaFraniere& Lehren, 2014].

Although journalists have uncovered a lot underneath the sometimes smelly rock that is military healthcare, perhaps this particular discovery was most disturbing: that the Surgeons General of the Army, Navy & Air Force frequently use an obscure provision in a 1986 law known as “Section 1102” to block disclosure of medical quality assurance records [LaFranere & Lehren, 2014]. This is a clever way to keep pesky Pentagon overseers at bay, so that nobody can truly keep track of how low quality of care for our service members has actually sunk. And if you don’t know how serious any problem is, then good luck trying to fix it.

And against that background, you depend on this organization to help you achieve a pregnancy? And if you succeed, that’s the place where you plan to experience labor & delivery? These are the pointed questions I hear from young military couples who are frustrated with the dismal service they say they get from clinics and hospitals “on base.”

Stories like that can’t help but make an impact. It probably explains why pregnancy announcements are hushed, rarely celebrated events during active duty. But not only is infertility & pregnancy care not a priority in the U.S. military, some of my patients have even felt that “the system” is designed to work against them. So, if you or your partner are military, and if you have found it necessary to seek medical help to establish your pregnancy, it may be difficult to do this unless you know what you’re up against. Until now, this part of the story hasn’t been told…it’s the reason this book exists.

I’m realistic enough to realize that no one book is going to change the U.S military. It will have to change itself, and its priorities will still be the same after you finish this book. But what will (hopefully) improve will be your awareness of the territory of infertility. The sections on billing and insurance, unfortunately, confirm that government support for troops and veterans—at least when it comes to assisted reproduction—remains essentially zero.

It’s not that children & family are irrelevant to the U.S. military. Actually, that’s far from the case. I believe in praising any organization that deserves it, and to the credit of our defense leadership, the U.S. military actually cares a great deal about your children. For example, it’s important enough for the Army to provide child development centers (for full-day care, part-day care and hourly care for children 6 weeks to 5 years old), family child-care homes offer (for full day, hourly, extended hours & long-term care in off-post residences), and even school-age services like before & after-school care. Where do you find that in the U.S. private sector? And this is only a partial list of benefits available to...