Infertility: The Hidden Cost of Orthopaedic Training

Editor’s note: This article is a companion piece to “Orthopaedic Surgeon Recounts Her Journey with Infertility,” below.

Resident physicians, particularly those specializing in surgery, often find themselves contending with the challenging decision to postpone pregnancy during their critical childbearing years, because those years are spent primarily in medical school and postgraduate training. The demanding and time-consuming nature of surgical training, in tandem with pregnancy-related stigma, unaltered work schedules, brief maternity leaves, and limited childcare support, contributes to the prevalent choice among surgical residents to delay starting a family until after completing training. A 2019 survey of obstetrics and gynecology residents in the United States revealed that 72 percent had postponed pregnancy due to the demands of residency. As age-related fertility decline becomes a significant concern, many physician trainees seek fertility-preservation options or pursue infertility treatments.

Although infertility affects one in eight couples in the general U.S. population, the incidence is one in four among female physicians. A surgical resident completes training at the average age of 36 years, aligning with the onset of declining female fertility (particularly after the age of 29 years), with a more pronounced decrease observed between ages 35 and 39. In contrast, male fertility begins to decline around age 45 years. The challenges of infertility are further exacerbated by a lack of awareness among young adults regarding age-related fertility decline and fertility-preservation options.

In response to the fertility challenges faced by female physician residents, the American Medical Association (AMA) recently enacted a policy supporting trainee access to assisted reproductive technologies. This policy aims to address both the time constraints and financial burden associated with pursuing these treatments, given that the average annual pre-tax income is approximately $60,000 for surgical trainees, and $15,000 to $20,000 is the average cost per cycle of oocyte harvest. The AMA policy encourages insurance coverage for fertility preservation and infertility treatment within health insurance benefits for residents and fellows in graduate education programs. Recognizing the stress and time constraints faced by residents in attending medical appointments for treatments, the policy supports accommodations for residents and fellows pursuing fertility preservation and infertility treatment. The Association of American Medical Colleges is also committed to supporting medical resident physicians who are trying to start a family; it has developed a Group on Women in Medicine and Science toolkit and webinars for medical resident physicians providing information on fertility benefits and other resources.

Despite these efforts, a survey of residency and fellowship program directors conducted in August 2019 revealed that a significant percentage were unaware of their program’s coverage for infertility treatment (57 percent) and fertility preservation (69 percent). Among general surgery residents and fellows surveyed in 2023, only 26 percent reported having coverage for fertility treatments, with less than 3 percent pursuing fertility preservation during training. Notably, 33 percent expressed the intent to pursue fertility preservation if covered by insurance.

To foster a culture of openness and acceptance and eliminate barriers for residents, transparency regarding available benefits is crucial. The top 50 medical schools in the United States for research were found to have varying degrees of information on fertility benefits for resident physicians, with only 40 percent explicitly mentioning them and 32 percent lacking any information on fertility or medical benefits. Moreover, information on coverage for third-party reproduction or LGBTQ+ family building was absent from all public websites.

Oocyte preservation, colloquially known as egg freezing, has gained widespread use since 2013, when the American Society of Reproductive Medicine removed its “experimental” designation. The process, which takes approximately 2 months to complete, involves a comprehensive workup by a reproductive endocrinology and infertility specialist, including assessments of ovarian reserve. Ovarian stimulation, requiring 1 to 3 weeks of oral contraceptives followed by daily injections of regulated hormone doses for 10 to 12 days, precedes egg retrieval—a minor surgical procedure which is performed under conscious sedation and takes about 15 to 20 minutes.

The demands of orthopaedic residency can greatly impact a trainee’s family-planning goals. Residents typically lack autonomy over their schedules, often live far from their families and support systems, and may be living on a tight budget. Oocyte preservation empowers trainees to decide when to start a family, enabling them to prioritize education in their late 20s and early 30s. Incorporating fertility options into medical benefits for orthopaedic residents can alleviate the financial burden of fertility-preservation treatments on a resident’s salary.

Importantly, this initiative sends a positive message to female medical students, reassuring them that orthopaedic surgery is a specialty where they can thrive as physicians while balancing family aspirations. Traditionally, orthopaedic surgery has been male-dominated, and there have been perceived barriers for women pursuing careers in this field. Actively promoting and supporting female representation in orthopaedic surgery challenges these stereotypes and reassures female medical students that they can excel in this specialty.

Margaret Higgins, MD, is an orthopaedic surgery resident at St. Luke’s University Health Network in Bethlehem, Pennsylvania.

Michael DeRogatis, MD, MS, is an orthopaedic surgery resident at St. Luke’s University Health Network in Bethlehem, Pennsylvania. He serves as a resident-at-large member on the Editorial Board for AAOS Now.

Dawn LaPorte, MD, FAAOS, is a professor, residency program director, and vice chair for education in the Department of Orthopaedic Surgery at Johns Hopkins in Baltimore, Maryland.

References

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