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The surprising facts about physician infertility

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Article

Because of our long educational path, physicians often start the process of building a family at a later age, which increases the risk of infertility.

In 2023, the Medical Student Section of the Florida Medical Association (FMA) submitted a resolution asking for recognition of the issue of physician infertility and more education on the topic. In response, the FMA hosted a webinar with experts on various aspects of physician fertility. This is the first article in a series about physician infertility based on that webinar.

Rebekah Bernard: ©Rebekah Bernard

Rebekah Bernard: ©Rebekah Bernard

As a kid who grew up in a trailer and received charity food baskets from the local church, I set my mind early on a career path that would lead to financial security. Acutely aware that an unintended pregnancy would put the kibosh on my self-funded education, I was diligent about taking precautions throughout college, medical school, and residency. By my early 30s, I finally felt that the time was right to start a family. I went off birth control, expecting a positive pregnancy test within a month or two.

One year and no baby later, I decided to consult with a local reproductive endocrinologist, who showed me a graph. “A 34-year-old woman who hasn’t gotten pregnant after one year of trying has a 3% chance of conceiving without medical intervention,” he said, pointing to my age on the figure.He launched into my options: Routine testing, of course, to make sure everything was working properly, followed by intrauterine insemination. If that failed, we would move on to in vitro fertilization (IVF), possibly with an egg donor.

My head began to spin.You see, I wasn’t even 100% sure that I wanted a baby—it just seemed like the next step in ‘normal’ human biology, as well as a societal expectation for a couple a few years into marriage. I had assumed that the second I went off birth control, pregnancy would be something that would just ‘happen.’ Now that there was a decision to make, it was clear that I had some serious thinking to do.

The facts about physician infertility

Infertility, defined as an inability to achieve pregnancy after a year of unprotected intercourse, affects an estimated 9-18% of American couples. For physicians, the rate is much higher, at about 25%. The main reason, as I learned through my own experience: Maternal age. Because of our long educational path, physicians often start the process of building a family at a later age, which increases the risk of infertility.

Reproductive endocrinologist Marcelo Barrionuevo, MD from IVF Florida, presented these facts to a physician audience from the Florida Medical Association. “The number one marker of fertility is female age,” he said, noting that peak fertility occurs at the age of 22, when the highest number and quality of eggs are present between both ovaries. Unfortunately, this is also the age when most women physicians-to-be are still in our pre-med college years.

According to Barrionuevo, while the chance of pregnancy occurring naturally without assistance is estimated at 20% per month for women between the ages of 20-29, a precipitous drop occurs around the age of 35, which is often the time what women doctors are finished with training and starting a career. Women in their 30s have a 10% natural pregnancy rate per month, dropping to 5% in our 40s.

In addition to lower chances of natural pregnancy, women over 35 also have lower success rates with interventions like IVF, because of a decline in quantity and quality of oocytes that can be harvested. “Forget the ‘40s are the new 30s,’” said Barrionuevo. “The ovaries didn’t get the memo, and the biological clock keeps moving forward.”

Medical trainees are unaware of fertility risks and options

Unfortunately, most medical trainees don’t get the memo either. According to one study, only 8% of women physicians surveyed said they received reproductive health education on the impact of delaying pregnancy. Reproductive endocrinologist Marcelo Barrionuevo notes that this is a serious deficit. “Everyone is looking at contraception during the years that women have the best chance of pregnancy,” he said. “We should talk to patients about fertility when we put them on contraceptives, because this gives women true reproductive autonomy.”

Indeed, many women physicians report that having had this knowledge would have impacted their life decisions. In one study, 53.5% of women physicians reported that they would have tried to conceive earlier if they had known about the risk of infertility. In another study, 17.1% of women physicians said they would have considered a different specialty, perhaps choosing a field with a shorter training period or with less physical demands.

The impact of specialty on family planning is a particular issue for women surgeons, who have more preterm births, more fetal growth problems, and more major pregnancy complications, including higher incidence of miscarriage than nonsurgical women physicians. Female surgeons operating 12 or more hours per week during the last trimester were at particularly high risk for major pregnancy complications.

In addition to earlier conception or a different specialty, 16.7% of women physicians reported that they would have used cryopreservation—freezing of embryos or oocytes—earlier in their lives if they had known infertility would be an issue.

Oocyte cryopreservation

While many physicians know about IVF for treating infertility, fewer are aware of the option of oocyte cryopreservation, or ‘egg freezing’ to preserve fertility.While initially used in the late 1990s to preserve fertility in women being treated for cancer, use of this technique has expanded to make way for women’s education, career, and to allow time to find the right partner.

According to Marcelo Barrionuevo, medical trainees should be aware of the option of oocyte cryopreservation, as new technology has dramatically improved success rates. “With the new vitrification techniques, as long as you are using a state-of-the-art laboratory, freezing eggs gives the same chance of pregnancy as freezing an embryo,” he said. In addition, he points out that oocyte freezing does not involve the same ethical and legal considerations as embryos.

Egg freezing starts with injections of an ovary stimulating medication for 8-12 days, followed by a 5–10-minute ultrasound-guided transvaginal needle aspiration. Oocytes are then frozen and can be stored indefinitely. The cost of oocyte preservation is estimated at $9,000 to 17,000 per cycle and a $300-500 per year storage fee (not counting the cost of future thawing, fertilization, and embryo transfer). Some private insurances and companies may pay for part of egg freezing, and Barrionuevo notes the availability of various financial assistance programs.

Because of the natural decline in oocytes with age, the best time to consider egg freezing is before the age of 35, when 14 mature eggs are needed to ensure an 80% chance of a future live birth. Waiting until after 35 requires more eggs to be harvested to achieve a successful pregnancy and may involve multiple cycles. Women considering oocyte cryopreservation should discuss the risks and benefits with their physician, as there are potential health consequences of both ovarian stimulation and pregnancy later in life.

A very personal decision

Speaking of risks, back to my own story. After talking with my reproductive endocrinologist, I decided to at least go through the first phase of a fertility work-up. My labs and scans were fine, and I agreed to try a round of a fertility medication called letrozole, as this sounded like a low-risk option.A few days after taking the medication, I was out for my usual neighborhood jog when I suddenly felt my legs go weak—so weak, in fact, that I was forced to sit down in the grass in someone’s yard. I wondered if I was going to have to call for help, but after waiting for a few minutes, I had the strength to slowly stand and then make my way home.

That was a scary moment; if a relatively benign drug like letrozole had that effect on me, how would my body react to the more invasive interventions that I would face on my fertility journey? I had watched many friends go through the physical and emotional toll of IVF, and I wondered if I could withstand the pressure along with the stress of my job and a marriage that was becoming increasingly shaky. Further, I pondered the philosophical question of trying to force something to happen that perhaps wasn’t meant for me.

Ultimately, I decided not to pursue more aggressive interventions, which turned out to be the right decision for me, as my husband and I divorced a few years later. I did remarry—the right partner this time, with whom I would have loved to share a child, but by then I was 42, quite comfortable with my life and all too aware of the risks of advanced maternal age.

The uniquely personal decisions that we make about our future start with having the best information, including the knowledge that our wants, needs, and desires may not always coincide with the ticking of our biological clock. In the next articles in this series, we will examine the journeys of physicians as they navigated infertility and the lessons they want to share with others. After all, with one in four women physicians facing infertility, we are not alone.

Rebekah Bernard, MD is a family physician in Fort Myers, FL and the author of four books, most recently Imposter Doctors: Patients at Risk.

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