COMMENTARY

Fertility Problems in Docs and Med Students: We're Not Alone

Emily Kahoud, MBS

Disclosures

November 04, 2020

Shortly after agreeing to write about my struggles in trying to have a child during medical training, I wanted to back out. "I should wait," I thought, "I shouldn't have done this until I actually had my baby." It's easier to look back and reflect on the darkness when you're finally out of the woods.

Right now, I'm still in the darkness. And I'm not alone, especially as a would-be mother in medicine. One out of four female physicians who responded to a survey published in the Journal of Women's Health had been diagnosed with infertility.

Emily Kahoud, MBS

I'm not yet a physician; I'm a nontraditional third-year medical student. I came back to medicine after having walked away when I was younger. Despite the persistent ticking of my biological clock, I found a passion to improve the lives of others through healing. I'm still (relatively) young and (generally) healthy, I thought. I can have a baby during training. At that time, I was also apparently quite adept at rationalizing the subtle changes in my body...

Many female physicians are surprisingly unaware about our inevitable and progressive decline in fertility. Research has shown that nearly half of ob/gyn residents overestimate the age at which this decline begins. Maybe our focus on identifying diseases in others blinds us to our own health considerations. My hope is that sharing my personal oversights, challenges, and lessons learned will help others to avoid the self-blame and isolation that I am currently experiencing.

Putting Off Pregnancy

My story is unique in that I was older than average when I first started medical school. It is not unique in that my husband and I postponed having kids because of our crazy work hours and because we just weren't "financially ready," given our combined mountain of educational debt.

I have also discovered that my personal experience resembles that of so many who have witnessed warning signs of fertility trouble and ignored them. For me, it was changes in my monthly cycles, which were growing shorter and less robust. I'm frustrated that, despite being a physician-in-training, I was blissfully unaware of the so-called "30th birthday cutoff."

One particular recollection haunts me: In my early twenties, I had been diagnosed with a condition that commonly causes infertility. My physician urged me to pursue pregnancy plans earlier rather than later. I'd like to say that I didn't understand her. The truth is, maybe I just didn't want to. I didn't even ask her a single question. At the time, the notion of having children was a fleeting thought about which I had very little emotional attachment.

Too many of us in medicine ignore red flags about our fertility early on. Detachment is necessary to our survival as doctors, so we feel vulnerable when we see ourselves as patients experiencing our own problems. This is particularly true for medical students, who commonly force fertility concerns to the sidelines. At this stage in our careers, the competition is fierce. We bury our fears and any desires that aren't related to learning.

Before making the decision a few months ago to step back from my education and focus on building a family, I was just starting a surgery rotation. By that time, my fertility situation was made clear to me: a pregnancy is highly unlikely if I continue to put my training first. I no longer have the luxury of postponing. The daunting hours associated with so many of our rotations, the inability to eat healthy food on a regular schedule, and severe deficits in sleep are the exact opposite of what my body will need to conceive.

So I made the difficult decision to take a leave of absence. This is something I never would have considered after finally starting medical school just 2 years ago. Making this choice means that my residency application could now get flagged or filtered. These are the decisions that prospective mothers in medicine are often forced into making. No wonder so many of us ignore red flags about fertility challenges.

Too Much Faith in Science?

Those of us in medicine who discover that trying to conceive is complicated may have a surprising source for our false confidence. Hina Talib, MD, associate professor of pediatrics and obstetrics & gynecology and women's health at the Children's Hospital at Montefiore in the Bronx, New York, points to our intimate relationship with science. Talib had difficulties becoming pregnant herself. She says that many of us overestimate the success rates of assistive reproductive technologies (ART) and underestimate our natural fertility decline.

"We have this inflated understanding of what ART can do," she said, "We have this idea of in vitro fertilization (IVF), for example, being very successful and very doable." We medical students should know that most IVF cycles fail, even for the youngest and healthiest of patients. The fertilized egg often cannot implant as a result of aneuploidy. Along with popular culture and news media depictions that promote a false-positive perception, our intimate medical knowledge gives us increased faith that these complex processes will inevitably work.

Even if they almost always did, even if ART was the guaranteed miracle we so desire, it is exorbitant and unaffordable for many of us. I have found that health insurance typically covers only two cycles of IVF, if they cover it at all. We are not Hollywood stars with infinite pockets. We have chosen careers that require a great degree of stamina and time management, not to mention educational debt.

We're even short of things that don't cost money, like time. Prior to medical school, I had a more regular schedule and greater control over being able to make and keep my doctors' appointments. I didn't anticipate needing them with such regularity. Trying to also meet the countless uncertainties associated with med school left me — like so many others looking to start their family — exhausted, demoralized, empty-handed, and isolated. So I had to walk away. For now.

We Are Not Alone

Despite the tremendous support that folks like me need, groups specific to those in medicine struggling with fertility are few and far between. Most of the ones that I have found thus far are exclusive to career stage. As a student, I haven't made the cut. The need to rely on Facebook groups or online chats is proof itself of how little help there is out there. This, despite how common the problem is in our community and despite our medical knowledge that fertility inevitably declines.

This lack of community is frustrating to me. Even if you aren't facing this issue yourself, we all know someone who has been personally affected by infertility. Women are understandably often the focus, but it affects everyone, including men and members of the LGBTQIA community who want to have a child. The list of those in medicine struggling with these challenges includes fertility specialists themselves.

Mark Trolice MD, director of Fertility CARE: The IVF Center in Orlando, Florida, is an avid patient advocate. He told me about his and his wife's struggle with 10 years of infertility. "It was just awful," he said, "I was suffocating with this horrendous devastation, and you're isolated and overwhelmed. It was surreal to be a fertility specialist, having your patients cry during the day, and then going home and seeing your wife cry at night."

I know those feelings. So many of us do, and yet so few of us share them.

That needs to change.

The American Medical Women's Association has begun to put fertility concerns among physicians and trainees front and center with a new committee, on which Talib is a leader. They have proposed seven major pillars of activism, in response to an article published in Academic Medicine titled "Physician Infertility: A Call to Action." The proposals include increasing fertility education and awareness, as well as advocacy for insurance coverage, family/parental leave, and flexible work policies.

Talib says that although medical students may not have pregnancy foremost on their minds, we should consider the issue as part of our general health and wellness. Combatting infertility in medicine will require that we simply share our experiences, like I have tried to do here. Those of us who have walked this path, or who are still walking it, know that early intervention and counseling can save many from pain, heartache, and even reproductive trauma.

"The right time [for pregnancy] is not when it's right for your medical school or your residency program," says Talib, "but when it's right for you." Medical institutions can show that they value family building. They can make it clear that if a student or physician wants to have conversations about fertility, the door is open. This alone would be a powerful way to allow us to consider our options without guilt or shame for wanting to seek treatment.

Moving Past 'Success or Failure'

For many, the pain associated with infertility means grappling with losing the dream of a traditional nuclear family. For those of us in medicine, this can spiral into the feeling that we, ourselves, are somehow "failures."

Many of us who pursue this profession are perfectionists. This common trait often lures us into a downward spiral of self-defeat. As a woman attempting to conceive, my self-critique has been harsh, despite knowing that I have no real control over the outcome. Maybe that's because I've grown so accustomed to the idea of being compared with others, ranked by everyone from admissions officers at medical schools to residency and fellowship program directors.

I'd like to challenge our tendency to define ourselves using binary terminology — success or failure — in regard to fertility outcomes or any of the other countless ways we self-evaluate. We have been trained to negotiate significant professional, mental, physical, and emotional demands without much self-compassion.

Research suggests that both high-risk pregnancies and miscarriages among doctors mirror the depersonalization and personal accomplishment elements that are associated with physician burnout. In the midst of the burnout crisis, experts suggest that we consider ourselves to be our first patients. That is to say, we must be the "patient" who gets our care before any of the others we treat. As someone facing fertility challenges, I can tell you that philosophy applies here too.

It's hard to share details of my personal life with strangers. I hope that by doing so, those of you reading this won't have to experience what I did. I hope you won't have the same pain I felt when my casual concern morphed into shock upon being told that we may already be too late to organically build a family.

I cannot save you entirely from the self-blame that I know all too well or the "what-ifs" that inevitably follow such news. I just hope that I can assure those already affected that you are not alone and empower others to consider family planning now.

Emily Kahoud, MBS, is a third-year medical student with a love for preventive medicine. She hopes to help combine her passion for healthcare with her desire to improve access to high-quality food in order to help patients fight the chronic disease epidemic. She dreams of having a clinic where every patient leaves with a bag of produce and not just a pocketful of prescriptions.

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