DEPARTMENT OF THE ARMY HEADQUARTERS, UNITED STATES ARMY MEDICAL DEPARTMENT 2748 WORTH ROAD BSA FORT SAM HOUSTON, TX 78234-6000 OTSG/MEDCOM Policy Memo 16-003 MCZX 2.1 JAN 2016 Expires 21 January 2018 MEMORANDUM FOR Commanders, MEDCOM Regional Health Commands SUBJECT: Gamete (Sperm and Ovum) Collection Issues for Active Duty Army Personnel 1. Purpose: To provide guidance on gamete collection issues for Active Duty Army personnel. 2. Proponent: The proponent for this policy is the Women’s Health Service Line, Patient Care Integration, Office of The Surgeon General, MEDCOM G-3/5/7. 3. Pre-Development Gamete Collection and Storage: In preparation for deployment, some Soldiers have indicated a desire to have their gametes collected and stored in the event that they sustain injuries that would preclude them from naturally parenting children in the future. Soldiers with medical conditions (e.g., cancer) and Soldiers who require medical (e.g., chemotherapy or radiation therapy) or surgical treatments that are gonadotoxic may also desire to collect and store their gametes to preserve the ability to parent children in the future. Additionally, Soldiers may desire to preserve their fertility until a later age and may become eligible for assisted reproductive technology (ART) later. a. Spermatozoa collection: (1) The Military Health System (MHS) does not have the facilities to store spermatozoa; however, spermatozoa and storage services are available throughout the US and in many foreign countries where US Soldiers serve. Soldiers wishing to collect and store spermatozoa prior to deployment must arrange these services well in advance of the scheduled deployment. (2) Because the MHS will not pay for gamete collection and storage, the Soldier will be responsible for all costs associated with these services. TRICARE provides coverage for infertility diagnosis and treatment, but specifically excludes gamete storage at this time. * This policy supersedes OTSG/MEDCOM Policy Memo 13-036, 28 Jun 13, subject: Gamete (Sperm and Ovum) Collection Issues for Active Duty Army Personnel.MCZX SUBJECT: Gamete (Sperm and Ovum) Collection Issues for Active Duty Army Personnel (8) Post-mortem Spermatozoa Collection for Active Duty Army Personnel: (a) The technology for harvesting sperm for deceased personnel has been available for several decades; however, the procedure itself is not available within most Army Health Readiness Platforms (HRPs). An individual requesting the post-mortem collection of gametes, from an Active Duty Soldier, must present previously signed, written documentation (i.e., advance directive, will, or signed document) from the Soldier that he/she is the Soldier's designated recipient of gametes collected post- mortem. This documentation must be presented to the HRP Commander (or designated representative), reflect that the Soldier has consented to the post-mortem collection of his gametes for the purpose of procreation, and specifically identify the individual requesting the collection of gametes as the person who should receive said gametes. (b) The HRP Commander, or designated representative, must inform the legal designated recipient, requesting the post-mortem collection of gametes, that all costs associated with collection, transport, and storage of the gametes will be borne by the recipient and not by the MHS, (c) In facilities that do not perform post-mortem gamete collections, the HRP Commander will ascertain whether facilities in the local community offer post-mortem gamete collection. If the procedure is available in the community, the HRP will generate a Memorandum of Agreement (MOA) with a facility that performs the services to delineate the administrative process for accomplishing gamete collection. The MOA will include the stipulation that the person designated to receive the gametes is solely responsible for all costs associated with the collection, transport, and storage of the gametes and that the MHS is not responsible for any portion of these costs. If gamete collection and storage services are not offered in the local community, there is no further obligation for the HRP to locate such services or to go to any other length to procure these services. (d) Once all required medical documentation and required mortuary services are completed, the HRP Commander may release the body of the deceased Soldier for transportation to a local civilian facility offering gamete collection. The Commander must ensure that there are no outstanding forensic or operational requirements (e.9., aircraft accident investigation) that would prohibit the release of remains to civilian providers or limit access to the remains by civilian providers. (e) Post-mortem gamete collection in the Theater of Operations (applicable to Soldiers Killed in Action or Died of Wounds) is not authorized, even if clinically feasible; due to constraints of the operational environment that presents challenges to positive identification of the decedent, the resolution of ethical or moral issues specific to the individual case, and the timely performance of gamete collection storage and shipping challenges.MCZX SUBJECT: Gamete (Sperm and Ovum) Collection Issues for Active Duty Army Personnel b. Ova Collection/Freezing/Storage for Future Use. Cryopreservation is the specific term for all stages involved in the cryostorage of the oocyte (“egg" or “ovum”) and refers to the freezing, storage, and thawing processes. While human spermatozoa and embryo cryopreservation have become routine, human ovum preservation has not yet reached consistent levels of acceptance or consistency. Whether ova are mature or not, standard cryopreservation technologies have limitations in terms of survival. (1) The MHS does not have the facilities to store ova; however, ova collection and storage services are available throughout the US and in many foreign countries where US Soldiers serve. Soldiers wishing to collect and store ova prior to deployment must arrange these services well in advance of the scheduled deployment. (2) Because the MHS will not pay for gamete collection and storage, the Soldier will be responsible for all costs associated with these services. TRICARE provides coverage for infertility diagnosis and treatment, but specifically excludes gamete storage at this time. 4. Soldiers Comatose or in Persistent Vegetative State: a. An individual requesting the collection of gametes from an Active Duty Soldier who is comatose or in a vegetative state must present the HRP Commander (or designated representative) previously signed, written documentation from the Soldier that he/she is the Soldier's designated individual to receive the gametes. This documentation must reflect that the Soldier consented to the collection of gametes for the purpose of procreation and has specifically identified the individual seeking the gametes as the person who should receive them. b. The HRP Commander or designated representative must inform the individual seeking the gametes that all costs associated with collection, transport, and storage of the gametes will be borne by the individual requesting these services and not by the MHS. c. In facilities where gamete collection from comatose patients is not available, the HRP Commander will ascertain whether a facility in the local community offers this service. If the procedure is available in the community, the HRP will generate an MOA with a facility that performs the services to delineate the administrative process for accomplishing gamete collection, The MOA will include the stipulation that the person designated to receive the gametes is solely responsible for all costs associated with the collection, transport, and storage of the gametes and that the MHS is not responsible for any portion of these costs. If facilities in the local community do not offer these services, there is no further obligation for the HRP to locate such services or to go to any other length to procure these services.MCZX SUBJECT: Gamete (Sperm and Ovum) Collection Issues for Active Duty Army Personnel d. Once the HRP completes all the required medical documentation and required services for the gamete donor, the HRP Commander may release the Soldier for transportation to a local civilian facilty offering gamete collection. The HRP Commander or designated representative will inform the individual designated to received harvested gametes that all costs associated with the transfer to and hospitalization at the civilian facility, as well as the cost of collection, transport, and storage of the gametes will be borne by the recipient, not by the MHS. MEDCOM developed an information sheet, “Reproductive Issues to Consider Prior to Deployment’, that is available for distribution to Soldiers as part of Soldier Readiness Processing (enclosure). 5. Assisted Reproductive Technology (ART) for Wounded Warriors: a. In 2010, the Assistant Secretary of Defense (Health Affairs) authorized ART (up to five total attempts or three successful cycles of IVF) as a benefit for Seriously or Severely illinjured (Category IVI) Active Duty Service Members. In order to be eligible for this benefit: (1) Soldier must be on Active Duty. (2) Soldier must have a Category III injury or illness classification. (3) Soldier's inability to reproduce naturally must be a result of the illness/injury that is classified as IV/Il. (4) The request for ART is for the injured Soldier and the Soldier's lawful spouse as defined in federal statue and regulation. (6) Both the injured Soldier and spouse must have gametes available to use for ART services (Soldier's or spouse's stored gametes are acceptable; donor gametes from other than the Soldier or spouse are not acceptable). (6) Both Soldier and spouse must be able to give informed consent for the ART services. MEDCOM does not authorize third party consent. b. Requests for ART services for Wounded Warriors will be routed through MEDCOM Clinical Policy Services (MCHO-CL-C), ATTN: Mr. Reynaldo Diaz, CDR USAMEDCOM, G-3/5/7 Clinical Services Policy Division, 2748 Worth Road, Suite 10, Room 103, JBSA Fort Sam Houston, TX 78234-6010, or email reynaldo.diazfernandez.civ @ mail.mi c. Costs for Wounded Warrior ART services (to include those of the non-service member spouse) will be funded through the Supplemental Care Program. 4MCZX SUBJECT: Gamete (Sperm and Ovum) Collection Issues for Active Duty Army Personnel 4d. DoD will cost share the costs of cryopreservation and storage of embryos for up to three years, 6. Compliance: a. Regional Health Command (RHC) Commanders will ensure that subordinate HRPs are complying with the requirements, in paragraph 5, regarding provision of IVF services. b. RHCs will request that HRPs that provide IVF services, or arrange for these services at a civilian facility for Soldiers, who have Category IV/Ililiness or injury to review the charts of two patients per quarter to ensure documentation of the following: (1) Soldier has documentation of Category IMI illness or injury. (2) Soldier's Category I/II illness or injury prevents Soldier from procreating naturally. (8) ART services were provided for Soldier and lawful spouse. (4) Soldier received preauthorization for ART services. c, RHCs will consolidate quarterly chart reviews, from subordinate HRPs, and submit to Clinical Policy Services on a yearly basis, NLT 31 JAN. FOR THE COMMANDER: Encls ULDRI IQAE, JR. as Chief of StaffREPRODUCTIVE ISSUES TO CONSIDER PRIOR TO DEPLOYMENT ‘Some male Soldiers have indicated a desire to have thelr sperm collected and stored before deploying in ‘ho event they sustain injuries that would prevent them from fathering children. Others have indicated that Inthe event of thelr deaths or lf they are ina persistent vegetative state, they would want their ‘wivestsignificant others to have the option to bear their child/children at some point in the future. Because the process can be lengthy, it should be Initiated will in advance of a Soldier’s deployment. ‘Some fernale Soldiers have also indicated a desire to have thelr ova (egys) collected and stored prior to deployment in the event they sustain injuries or medical conditions that would prevent them from having children. Because ova storage technology is not as advanced as sperm storag fs remains ‘experimental at this time. This process Is extremely longthy so Soldiers wishing to undertake this ‘process must initiate the process well before the time of deployment. elther of these options Is being seriously considered by the Soldier, the following need to be considered: (1) Consult with an attomey and Chaplain or other fe counselor before making a final decision. Discuss what your rights are 2s the donor, what the rights are of the person to whom you have designated responsibilty for the sporm or ovum, and what the rights are of the future human who Is conceived from the frozen spermiovum. (2) These issues are not ones to consider when a Soldier is feeling pressured - from a spouse, life partner or other family members - nor in the final days before helshe deploys. Questions such as the ‘stably of the relationship between the Soldier and the spermiovum recipient, the amount of support that can be expected from extended Families the abiity of the reciplentiextended Families to work together to ‘alse a child, and the Soldier's ability to understand hisfher own motivations to have the procedure will take ‘an extended period to work through. These Issues are not the only ones to be considered, and they are not single issues, they are inter-related, and the decisions made will have lasting effects on multiple individuals, (9) The issue of whether or nota child resulting from post mortem conception wll be eligible for tmiltary benefits, including healthcare benefits, is uncertaln and will be addressed on a case-by-case basis. ‘Sperm Collection from Active Duty Soldiers ‘The ttttary Health System (MHS) can provide information on sperm collection for future use but sperm storage banks are not available through the MHS. The Soldier will be responsible for all costs associated with aperm collection, transport, and storage. The MHS will not be responsibte for such costs, The Soldier should ensure that he designates a next-of-kin with the sperm storage facility to ensure that the sperm ‘ae released to his designated individual in the event of his death. ‘Should an individual request colisction of sperm from a Soldier who died at an Army treatment facility or sin a comatose/persistent vegetative state, the military treatment feclity Commander must be provided ‘with the prior written consent of the deceased Soldier authorizing sperm collection for the purpose of atternpting to create offspring. The written consent must specifically dentiy the recipient of the eperm as the individual seeking the sperm. (Many Army troatmont fecilifes do not perform sperm retrieval from deceased or comatose personnel. In those faciities unable to perform the procedure, the military treatment facility Commander may direct that the comatose or deceased Soldier be eent to a local civilian facility offering the procedure (sperm ‘atrlaval) a8 tong as there are no forensic or operational (eg, aircraft accident Investigation) concems that ‘would prohibit the release of the Soldier's remains {in tha case of the deceased) to civilian providers or limit access to the remains by elvlian providers. Eur‘Sperm collection from a decased individual is a time-sensitive procodure which should be performed as. ‘soon as possible, proferably immediately following the declaration of death, {fsperm retrieval from comatose or deceased personnel must be done In the local community, the military treatment facility will generate a Memorandum of Agreement with the focal facility to define the ‘administrative process for accomplishing sperm collection. If this procedure fs not offered in the local community, the miltary treatment facility is under no further obligation to locate such services. ‘Tho individual designated by the Soldier as reciplent of the sperm is responsible for all costs associated ‘with sperm collection, transport and storage and in the case of a comatose Saldlor, the hospitalization costs at the civilian medical facility. The MHS will not be responsible for such costs. ‘The option far sperm retrieval from a Soldier who has died on the battiefield or in a combat zone does not exist. ‘Ovum (Eng) CollectionfFreezing/Storage for Active Duty Soldiers. ‘The technology to freeze and store ova (eggs) for future use Is not as well-advanced as that for sperm collection and storage. Cryopreservation technologies (al stages involved in the freezing, storage and ‘thawing processes of the eggs in czyostorage) ara limited causing the loss of a significant number of the of eggs in the froezingithawing process. Additionally, studies have shown that eggs that have gone through the cryopreservation process do not fertilize wall after thawing. ‘An altemative procedure is to freeze (cryopreserve) a whole ovary or parts of an ovary in an attempt to ‘save the tissue containing eggs for future use. This tachnology is avallable, but is not very advanced. This, [procedure is accomplished by placing this tissue directly back Into the woman's body, or by using this. {issue in a laboratory to grow the eggs entirely outside of the body. Once the egg has matured and has been fertitzed by sperm in the laboratory fin-vitro fertilization”), t could be placed into the female uterus, (womb). ‘Ovum retrieval is accomplished primarily by the following means: by a surgical procedure In which an Incision is made through the abdominal wall (laparotomy) or by insertion of a needle Into the ovary while undergoing art ultrasound. ‘The MHS can provide information on ovum collection for future use but ovum storage banks are not avallable through the MHS, The Soldier will be responsibie for at! costs associated with ovum collection, transport, and storage. The MHS will not be responsible for such costs. The Soldier should ensure that ‘she designates a next-of-kin with the ovum storage faciity to ensure that the ovum Is released to her designated Individual in the event of her death. TRICA R (s ction prage TRICARE provides coverage of infertilty diagnosis and treatment but the family planning benefit excludes ‘coverage for “services and supplies related to non-coltus (non sexual intercourse) reproductive technologies", including in-vitro fertitzation for which sperm and/or ovum collection would be utilized. Resources Avaliable resources include, butare not imited to, the following: ‘Yourheatthcare provider Fatfax Cryobank ‘Calfomia Cryobank ‘American Society for Reproductive Medicine ta foe prot tran iy nso tb nso negra by OTSGMEDCOM orb Dope