Citation Nr: 21026534 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 07-31 352 DATE: May 3, 2021 REMANDED Entitlement to service connection for infertility, to include as secondary to service-connected posttraumatic stress disorder (PTSD) with depression, is remanded. REASONS FOR REMAND The Veteran had active military service from March 1985 to March 1989. This case initially came before the Board of Veterans' Appeals (Board) on appeal of a November 2005 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In April 2009, the Veteran testified before a Veterans Law Judge (VLJ); a transcript of that hearing is associated with the claims file. In February 2011, the Veteran was notified that the VLJ who conducted her April 2009 hearing was no longer employed at the Board, and of her right to be afforded another hearing under However, in a March 2011 statement, the Veteran declined another hearing. This case was previously before the Board, most recently in December 2020, at which times the issue on appeal was remanded for additional development. The case has been returned to the Board for further appellate action. The Board sincerely regrets additional delay but finds that another remand is warranted to ensure that the Board has a complete record upon which to decide the Veteran's claim. In the December 2020 Board remand, the Board instructed a VA examiner to do the following: (1) address whether the December 2000 Clomid treatment recommendation was related to infertility issues; (2) determine whether the Veteran had a diagnosis of infertility at any point during the appeal period and whether her infertility was related to military sexual trauma, or, proximately due to, or aggravated beyond its natural progression by, her service-connected PTSD due to sexual assault with recurrent major depressive episodes. In a January 2021 addendum opinion, a VA examiner opined that it was less likely than not that the Veteran's Clomid treatment recommendation was related to infertility due to polycystic ovary syndrome (PCOS). The VA examiner reasoned that the physician's notes suggested that the use of clomid for PCOS related to irregular periods. The VA examiner also noted that PCOS was a known cause of infertility but that no extensive infertility workup was done beyond the PCOS diagnosis. Additionally, the VA examiner noted that Clomid could be used to restore cycles and fertility but that there was no actual indication that the Veteran actually took Clomid. The VA examiner further noted that the Veteran requested birth control subsequent to the suggestion of taking Clomid; had not been treated for PCOS or infertility per VA records over the last 15 years; and that sexual assault did not cause irregular menses. Finally, the VA examiner noted that the Veteran had reached menopause and was not fertile. The January 2021 VA examiner also assessed that the Veteran's prior diagnosis claimed as "infertility related disability" was less likely as not related to military sexual trauma (MST). The VA examiner reasoned that the weight of medical literature was against MST causing infertility, as infertility was related to hormonal and anatomical abnormalities. Further, the VA examiner assessed that the Veteran's PCOS was less likely than not aggravated beyond its natural progression by her service-connected PTSD. The VA examiner noted that the weight of the medical literature was against a mental health condition causing or aggravating infertility and that PCOS was associated with obesity and hormonal imbalance. Finally, the VA examiner opined that the Veteran's prior diagnosis of PCOS was at least as likely as not the cause of her claimed infertility. The VA examiner reasoned that PCOS was associated with infertility. The Board finds that the January 2021 VA opinion is inadequate for adjudication purposes. In that regard, the VA examiner also noted that PCOS was not associated with mental health conditions but failed to acknowledge medical documentation that several of the Veteran's psychiatric medications caused her to gain weight. Additionally, the VA examiner failed to properly note that the Veteran made complaints of infertility in December 2000 prior to being diagnosed with PCOS or receiving the recommendation of Clomid. Additionally, the VA examiner noted multiple times that the Veteran did not request fertility treatment. However, the Board notes that a failure to request fertility treatment does not in and of itself indicate that the Veteran was not infertile. Finally, the VA examiner related the Veteran's infertility to PCOS, but also seemingly related her current infertile status to menopause. As such, the Board is not entirely clear as to whether the VA examiner assessed that the Veteran's infertility predated the start of her menopause or was the result of her menopause. Additionally, the Board notes that in a recent decision, the Court held that service connection may be grated on a secondary basis where the claimed disability would not have occurred but for obesity caused or aggravated by a service-connected disability. See Walsh v. Wilkie, 32 Vet. App. 300 (2020). Further, obesity may serve as an intermediate step between a service-connected disability and a current disability that may be service connected on a secondary basis under 38 C.F.R. § 3.310(a). Therefore, the Board finds that the development conducted does not adequately comply with the December 2020 Board remand directives. Compliance with a remand is not discretionary, and failure to comply with the terms of a remand necessitates remand for corrective action. Stegall v. West, 11 Vet. App. 268 (1998). The matters are REMANDED for the following actions: 1. Forward the entire claims file, to include a copy of this remand, to a VA examiner who has not previously rendered an opinion in this appeal. The VA examiner MUST review the ENTIRE claims file, and that review must be noted in the report. Based on a review of the record the VA examiner must determine whether it was at least as likely as not (50 percent or better probability) that the Veteran's Clomid treatment recommendation was related to infertility issues. In forming this opinion, the VA examiner must discuss the treatment records showing that the Veteran was being seen for difficulty with conception when prescribed Clomid, and was diagnosed with PCOS within two months after those complaints. The VA examiner must also determine whether it was at least as likely as not (50 percent or better probability) that the Veteran's menstrual issues, to include her in-service complaints of menstrual cramps and post-service documentation of irregular period were related to infertility issues, to include her diagnosis of PCOS. The VA examiner should also provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that the Veteran's obesity was caused or aggravated by her service-connected psychiatric disability, to include any related medications prescribed for treatment of such. If so, the VA examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that the Veteran's obesity caused or aggravated her PCOS or infertility. A complete and detailed rationale must be provided for all opinions expressed. A physical examination of the Veteran should only be conducted if deemed necessary by the examiner providing the requested medical opinions. 2. Confirm that all medical opinions comport with this remand, and undertake any other development determined to be warranted. 3. Then, readjudicate the appeal. If a decision is adverse to the Veteran, issue a supplemental statement of the case and allow appropriate time for a response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Byrd, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.