Income over insurance: rethinking access to fertility care in veterans

It should be no surprise that, following increasing roles of women in combat and increasing military operations over the past 25 years, women comprise the fastest-growing demographic in the United States Veteran population (1). Ensuring equitable access for these women to comprehensive reproductive care is vital to pay respect to them for the service they have provided. According to the US Department of Veterans Affairs (VA), infertility is the inability to achieve a successful pregnancy as determined by a patient’s history, age, clinical findings, diagnostic results, or the need for medical interventions, such as donor gametes or embryos. All enrolled veterans, regardless of service connection, relationship, or marital status, have coverage for basic fertility evaluations and treatments under the VA Medical Benefits Package. A veteran must have or be treated for a Veterans Benefits Administration (VBA) – determining an adjudicated service-connected disability that directly caused the infertility, to be eligible for VA Assisted Reproductive Technologies (including In Vitro Fertilization), otherwise, these treatments must be funded out-of-pocket by the veteran.

Although a small number of reproductive endocrinology and infertility physicians are providing care to the VA, there may be roadblocks in place that limit a veteran’s ability to seek consultation for infertility. The manuscript in this month’s F&S Reports, “Associations Between Social and Economic Determinants of Health and Receiving Infertility Care among Female Veterans: A Cross-Sectional Study,” by Pleasure et al (2), sheds light on the socioeconomic barriers that female veterans encounter when seeking reproductive health care (2). This research highlights the specific needs of female veterans and the implications of social determinants in shaping health outcomes. Study interviews were completed by 1,410 female veterans, with 589 meeting the proposed clinical criteria for infertility. Within this eligible cohort, 22.8% (n = 134) reported that they or their partner had received an infertility diagnosis, and almost 20% of the cohort (n = 115) reported receiving fertility treatment. Notably, veterans who received a diagnosis or treatment were significantly more likely to be married or cohabitating, and to have a household income exceeding $110,000. Conversely, the researchers observed no statistically significant differences in diagnosis or treatment based on race, sexual orientation, or VA insurance status.

The findings by Pleasure et al. (2) contribute to a growing body of literature suggesting that access to infertility care among female veterans remains influenced by factors beyond insurance coverage alone. Although all enrolled veterans are eligible for basic infertility care through the Veterans Health Administration as described above, this study mirrors prior studies that have demonstrated that only a minority of female veterans with infertility ultimately receive infertility evaluation and treatment, with many seeking care outside of the VA system (3). Pleasure et al. (2) further highlight this paradox by finding that insurance status did not significantly impact diagnosis or treatment rates (2). Collectively, these findings suggest that the availability of benefits does not necessarily translate into equitable utilization of services, revealing a critical unmet need for reproductive health care among female veterans. This gap could be partially mitigated through targeted educational initiatives regarding available VA benefits.

The association between higher household income and receipt of infertility care identified in this study is consistent with existing qualitative literature. Previous work among veterans undergoing fertility treatment has highlighted challenges navigating referral pathways, understanding eligibility requirements, coordinating care between VA and community providers, and managing the logistical demands associated with specialty infertility services (4). These systemic barriers are likely to disproportionately affect veterans with fewer financial resources, less workplace flexibility, or limited access to transportation, providing an explanation of why income matters.

Although Pleasure et al. (2) did not observe statistically significant racial or ethnic disparities in care, such disparities are well documented in both veteran and civilian literature. A prior study of veteran populations demonstrated lower utilization of infertility treatment among racial minority women despite similar rates of infertility evaluations (5). It is unclear why this discrepancy exists, but likely due to both sample size and use of multiple racial/ethnicity categories in the present study. These findings underscore the need for continued research examining how social and structural determinants influence reproductive healthcare access among female veterans.

The use of a geographically diverse, national sample of veterans in the study by Pleasure et al. (2) provides an in-depth snapshot at the utility of infertility services in the growing US Veteran population. Conversely, the data herein was drawn from a primary study investigating the impact of military sexual trauma and combat-related trauma on fertility, and may therefore impart selection bias in this study, a known risk on such analyses. Veterans who chose to participate in the initial survey may have been disproportionately affected by these concerns, potentially introducing bias into the data. Furthermore, veterans experiencing sexual or combat trauma are statistically more likely to use behavioral health services. This increased touchpoint with the VA healthcare system naturally grants them greater overall access to medical screenings, potentially leading to higher rates of infertility diagnosis and care than those who are less integrated into VA services.

This study raises important questions for future research. Although this cross-sectional study highlights important associations, it cannot establish causality; therefore, further research is necessary to clarify the specific mechanisms through which social determinants dictate infertility care-seeking behaviors among veterans. Future qualitative studies exploring patient-perceived barriers, healthcare navigation challenges, and decision-making processes may provide additional insight into the patient experience. Additionally, longitudinal studies would help identify specific vulnerabilities within the infertility care continuum. Moving forward, these findings represent a call to action for the Veterans Health Administration to implement targeted reproductive health initiatives, ensuring that infertility services are genuinely accessible in practice, not just in policy. This body of literature greatly underscores for clinicians, researchers, and policymakers that equitable access to infertility care for veterans is deeply shaped by socioeconomic conditions, highlighting the need for comprehensive, system-level solutions.

CRediT Authorship Contribution Statement

Allison P. Watkins: Writing – original draft, Writing – review & editing. Bruce D. Pier: Conceptualization, Methodology, Writing – original draft, Writing – review & editing.

Declaration of Interests

A.P.W. has nothing to disclose. B.D.P. reports travel support and honorarium from Pacific Coast Reproductive Society.