At VA Boston, Carolyn Mason Wholley works with women who’ve served to connect them with the care they need. Sometimes, that means helping veterans with fertility.

Insurance under Veterans Affairs covers some tests and procedures, like artificial insemination and egg freezing. But there are strict rules, set at the federal level, for who qualifies for in-vitro fertilization.

“Unfortunately, I think there are more people than not that don’t meet the criteria for IVF that has been sent down from the directive from central office — and from Congress, really,” Mason Wholley said.

For veterans to qualify, they have to be married and, within their marriage, they have to be able to provide both the sperm and the egg — no donors. Plus, they have to have a service-connected disability that is linked to their infertility.

In the last six months, Mason Wholley estimated that she’d sent out six to eight denials of coverage — and that “much fewer” have been eligible.

The issues with IVF coverage caught Massachusetts Gov. Maura Healey’s eye as an issue of equity, and her administration is pursuing a pilot program. And now, national changes are also on the horizon.

The nationwide movement

At the federal level, the policy is changing in response to a discrimination lawsuit filed last year, per court filings. Active service members — and, it seems, veterans, too — will no longer need to be married or need to produce their own sperm and eggs. That means many LGBTQ+ couples, single veterans or unmarried opposite-sex couples would qualify for coverage for the first time.

The policy change, which will apply to a small subsection of the roughly 20 million veterans and active service members eligible for care, is being celebrated by advocates and providers.

IVF is a fertility treatment that often comes after other options have been exhausted. It requires fertilizing the egg outside of the body and then placing the embryos into the person’s uterus. And it often takes multiple cycles to achieve pregnancy, if it works at all. Data from the Society for Reproductive Technology shows that about one in three people under 35 will have a child on their first try with IVF. Without insurance coverage, it can cost tens of thousands of dollars for a single cycle.

Renée Mihail, who served in the Army and is now a law student working on the suit at the Yale Law School Veterans Legal Services Clinic, said the policy change signals that the government recognizes its policies were discriminatory.

“I’ve spoken to so many of my friends who have had to deal with their own fertility issues and have to handle things out of pocket, and just all of these sort of complicating factors going into trying to build their families,” she said. “And so it was really exciting, especially when VA said that it was going to ultimately follow suit.”

Some see it as an important step to getting outdated policies off the books.

“Even though ‘Don’t Ask, Don’t Tell’ was repealed more than a decade ago at this point, there's still unfortunately quite a bit of tension around what benefits same-sex couples should and shouldn't have,” said Kyleanne Hunter, a senior political scientist at the RAND Corporation who focuses on women’s issues in the military and is herself a veteran.

Kristin Mattocks, UMass Chan Medical School’s associate dean of veterans affairs who studies reproductive health issues among veterans, spoke with many of the veterans who’ve received the IVF benefits for a 2021 study and found the limitations on benefits made it difficult or impossible for some to conceive.

“If you need to use donor eggs, nothing is covered,” one New York veteran said for the study. “It’s not always the Veterans fault that we can’t get pregnant.”

The VA told GBH News that 2,562 veterans and their spouses have used the benefit since it was first rolled out in 2017. Mattocks pointed out that the number of veterans approved doesn’t include those who were denied, or never applied because they knew they wouldn’t qualify.

“I don't know if anyone knows that number — I mean, I certainly don’t,” she said. “But that number is way bigger.”

It's not yet clear when the policy will change. For active service members, the Department of Defense will roll out details of its policy in late February, per filings. Since the veterans’ policy is currently tied to the active service members’ policy through federal legislation in yearly Congressional appropriations, the veterans’ policy will change with active service members’. But, going forward, Congress could amend how the change is implemented for veterans.

Denis McDonough, the VA secretary, said at a press conference last week that he’s sought to change this policy since he took the post.

“Since [Department of Defense] is changing that memo, we, too, will change our policy,” McDonough said, explaining the court filings. “The intent ... is consistent with an intent that we’ve had since we arrived — which is to increase opportunities for access among more veterans for IVF.”

What could be changing in Massachusetts

The state's pilot program — tucked into the sweeping veterans’ services reform bill, the HERO Act, that Healey filed in November — would cover IVF costs for couples denied solely because they’re in same-sex marriages.

Jon Santiago, Massachusetts’ secretary of veterans’ services, says the idea came from another discrimination lawsuit filed over this policy, this one by a Massachusetts resident.

“Bottom line is that veterans have served our country, and they shouldn’t have to sacrifice when it comes to building a family,” Santiago said. “And so when we thought about the IVF component ... there was the Ashley Sheffield case. And that sparked an interest: it did not seem fair, did not seem equitable.”

Sheffield tried several cycles of artificial insemination during her nearly two decades of service in the Air Force. After retiring from the military, she decided to try in-vitro fertilization.

Sheffield was injured during her service — injuries that affected her fertility, per her court filings. And she’s married. But, under current VA policy, she had a problem.

“You are not qualified if your [sic] in a same sex marriage or if the sperm is donated from someone other than a male spouse. I am sorry,” her case manager at VA wrote her, according to court filings.

Jon Santiago, then a Massachusetts state representative and ER doctor, stands outside of the emergency room entrance at Boston Medical Center in Boston on April 8, 2020.
Meredith Nierman GBH News

Santiago estimates that there are fewer than 50 couples that would become eligible for this benefit under the Massachusetts pilot. Massachusetts’ state-level initiative would affect a smaller group than the federal changes since it’s more narrowly tailored to same-sex married couples than, for instance, unmarried couples of any gender or single veterans.

“Ms. Sheffield is extremely moved by the Healey Administration’s dedication to advancing the rights of LGBTQ+ veterans, and is honored to learn that her bravery in coming forward has inspired the creation of a pilot program that will serve to protect a vulnerable subset of the veteran population from acts of invidious discrimination,” her attorney, Michael Stefanilo Jr., wrote in an email to GBH News.

The pilot is far from becoming law: the HERO Act is waiting in the Legislature for movement from the House and Senate. But despite machinations at the federal level, Santiago says there are no plans to change the proposed pilot.

“Here in Massachusetts, we don’t wait. We move forward with action,” Santiago said. “And we’re not going to wait on the federal government that, right now, may be a little bit slow to act.”

What comes next

The requirement that veterans have a fertility issue due to their service would still be on the books, which is considered the biggest barrier to getting coverage for IVF treatment.

Just how limiting that requirement is is unclear. Some members of the military suffer visible injuries to their reproductive organs, but others are exposed to chemicals that could affect their fertility. Experts said those veterans struggle to prove that it’s an issue of their service. Others still have fertility issues that are unrelated to their time in the military. Mattocks found that many veterans who had received their fertility-related diagnoses, like endometriosis, during their service qualified for coverage.

Mason Wholley said that, when she’s referring veterans out, it’s the requirement veterans most often don’t meet.

“One of the biggest barriers is still remaining, right?” said Freya Riedlin, acting senior federal policy counsel at the Center for Reproductive Rights. “We’re very excited to see that these discriminatory restrictions, based on marriage and providing their own gametes, are being lifted. ... But, there’s still a lot more to be done.”

Mihail, at Yale, said the restriction stands out from the many other benefits offered through VA, even other fertility treatments.

“I can go to the VA for anything that arises, regardless if it was a service-connected injury or not,” she said. “But I would need to prove that my infertility is a result of my service in order to get IVF — which is, again, different than all other forms of health care, except for dental, in the VA.”

Here in Massachusetts, too, more research would happen under the HERO Act to identify areas of discrimination in veterans’ care. Santiago pointed to recent findings that Black veterans’ requests are more likely to be denied by the VA.

“Part of the legislation is not just the pilot for IVF, but is also understanding, analyzing: are there other places in VA medical system where this might be occurring?” he said.