Birth rates in the United States have been on a relatively constant and significant downward trajectory since the 1950s. While medicine has improved in the field of infertility, many still struggle with the issue. This episode of SoundPractice focuses on fertility and women in medicine.
This transcript has been edited for clarity and length.
Mike Sacopulos: My guest today is Jenna Miller. Dr. Miller practices pediatric critical care medicine. She is also the author of Navigating Your Fertility as a Woman in Medicine. Jenna Miller, welcome to SoundPractice.
Jenna Miller: Thank you for having me.
Sacopulos: It is our pleasure. As you know, this is the podcast of the American Association for Physician Leadership. Before we discuss your book, could you please describe your journey as a physician leader?
Miller: Absolutely. I went to medical school and did my residency in Kansas City at the University of Kansas and then Children’s Mercy, Kansas City, for pediatrics. I went to Texas Children’s in Houston to complete my pediatric critical care training and then was lucky enough to come back home to Kansas City. I have been practicing here for 10 years.
In my leadership roles, I started as associate director of the fellowship program and then became the fellowship director. I was in those roles for nine years. Currently, I am the extracorporeal membrane oxygenation (ECMO) director, but during my time as fellowship director, I really started to better understand the needs of my trainees in tandem with my own story of fertility, or infertility, as it turned out.
I understood that we were not doing a great job of preparing people for navigating this road in a profession where our trainees are graduating and starting their families at a later age than the general population. So that is how I really came to be interested in starting advocacy work in this field surrounding fertility for our colleagues in medicine.
Sacopulos: As we mentioned, your book is Navigating Your Fertility as a Woman in Medicine, and I think you were starting to get to this place, but maybe you could tell us how you came about writing the book.
Miller: A disclaimer: I am not a reproductive endocrinologist. I leave the medical decision-making to the patients and their physicians, and the expertise that our colleagues in that field have around the guidance and medication regimen is not something I wish to emulate.
I’m here more to be an advocate for awareness of the basic biology that you would think we would all have learned and gained knowledge about in medical school, as well as what to expect in non-traditional ways to form a family that many of the women and people in medicine have come to find they are needing.
The goal of this book was to share my own personal experience, which spans seven years in the reproductive endocrinology world and finally led to pregnancy in a gestational carrier for me. I am due next month, so I am pretty excited about that. But to share that experience along with the evidence that I have read along the way, information that I’ve received and learned from my experiences in these clinics, all in one resource for people to have as a beacon or a guideline or a map of how to navigate what an entirely new world of vocabulary and treatments is.
Sacopulos: Well, I need to start by saying congratulations. That is exciting news. Let’s dig in a little bit more into the statistics or background. How many people are currently dealing with infertility in the United States, and how does that compare with the number of physicians dealing with infertility?
Miller: That is a really good question. The most recent numbers on the CDC website are one in five, or 19%, are unable to get pregnant after a year of trying, which is the definition of infertility for those younger than 35. For those older than 35, infertility is more than six months of trying without conceiving. The number of people who have trouble getting pregnant and maintaining a pregnancy is one in four in the general population.
Sometimes people think this is a problem that affects only those who are first-time moms; however, those who are going on to have a second or third or however many pregnancies after that also experience this in the general population, and up to 14% of those have difficulty getting pregnant or carrying a pregnancy to term.
So, it is not just first-time parents who have this experience; it can also be for people who have already carried a pregnancy successfully.
Data from a 2016 paper suggest one in four graduated female physicians experiences infertility. A study since then states that 29% of OB/GYN residents report infertility. And in 2021, 25% of our female surgeons reported infertility. This number seems pretty well-validated across multiple reputable studies that are peer-reviewed. And over the last seven years, these numbers seem pretty static.
However, in recent years, the CDC numbers have gone up by 5% in the general population. They previously reported 14% and now report 19%, so it is possible that this trend is going to appear in statistics for our colleagues, but we have not seen that uptick to 30% just quite yet.
If we did see that trend in our colleagues, then we are talking about closer to one in three of our female professionals who are experiencing infertility, which is very concerning when we realize over half of our workforce-to-be in medical schools is now women.
Sacopulos: Absolutely. So, what are some of the differences in how physicians experience pregnancy as compared to members of the general population?
Miller: We think about traditional residency and fellowship paths for those who went through college and then went to med school, went straight into residency and fellowship. We are talking about late 20s and early 30s, and this overlaps with typical childbearing years.
As we also know, the rigor of these programs sets trainees apart from their same-age counterparts and leads to higher average age of first pregnancy than the general population by about four years.
We have not focused on this historically when we are talking about supporting reproductive health in our field. As I mentioned earlier, more than 50% of our medical school classes are now women, so when we are talking about protecting our workforce in the future, it is really important that we provide this knowledge and awareness and planning for over half of our workforce-to-be. Who is in charge of that planning, and how do we access those trainees?
In 2021, the ACGME surveyed their program directors, and two-thirds of those who responded had never been approached about trainee fertility concerns. About two-thirds of them did not know their institution’s practices on insurance coverage for infertility.
Our field has unique challenges that make this topic extremely important for us to broach in an open dialogue. Infertility is associated with early attrition from our field. We know that we lose some of our female workforce within seven years of them completing their training. Burnout related to infertility is sometimes identified as part of that attrition, so it is important for us to address that.
How are their pregnancies different? Our colleagues experience not only higher infertility rates than the general population but also higher miscarriage rates. Our female surgical colleagues have almost twice the miscarriage rate and risks of pregnancy complications. Additionally, as far as mental health goes, our surgical colleagues and those who deliver during a residency have higher rates of postpartum depression.
Sacopulos: That is interesting and sad. What are some typical ages when physiologic changes occur in the reproductive system, and how can a woman be proactive in preserving her fertility?
Miller: Our peak reproductive years are our late 20s, early 30s — our prime training years. By age 30, a woman’s fertility starts to decline, with more rapid declines by mid-30s. When you are over 40, the chances of a natural pregnancy become much lower.
Our ovarian reserve dictates our chances of achieving a pregnancy. This measures the number of eggs, or oocytes, we have available to us during any reproductive cycle. As we age, that number and the quality of what is there decreases. A number of factors can affect ovarian health apart from age, including genetic history, stress, and environmental exposures, but age is the most obvious one across the board.
So, if you want to be proactive about fertility preservation, what people commonly refer to as freezing your eggs, you are looking to potentially do that before the age of 30, which for people on a traditional path in medicine is during residency.
In my book, I encourage those who wish to have a family and do not have a current plan to consider evaluating their fertility and exploring preservation during training or even while in medical school. I think medical school is a place where we can at least raise the issue for our trainees and put it on their radar as, “Yes, you’re busy now, you’re focused, you’re studying, and that’s excellent, but keep this in your mind because it can sneak up on you and it commonly does.”
Obviously, during training, during medical school, fertility preservation, or fertility treatments are complicated by financial and scheduling difficulties.
The rigor of fertility treatment cannot be overstated. There is a physical toll, an emotional toll, and time requirements that are inflexible. Our job is also inflexible, so you put these two inflexible things together, and it is difficult and stressful.
Sacopulos: In your book, Navigating Your Fertility as a Woman in Medicine, you talk about how to select a clinic. And I am interested not only in how someone should select a clinic, but also, for women in medicine, if there are privacy issues that members of the general public may not face. Could you comment on that?
Miller: Regarding the privacy issue, the general HIPAA rules apply: Your physicians are not allowed to speak to other people about your treatments. But in busy clinics, you may run across people you know — I have certainly experienced that.
I do not know if there is a way around that, apart from speaking with your physician about trying to get the earliest appointments or times that are less busy. But when you’re in a cycle, the appointments are very regimented, and everyone in this cycle is coming at this time.
It is difficult to avoid being seen in a clinic, especially if your city has only one or two available to you. In the book, there is a chapter dedicated to finding clinics and preparing for treatment. Depending on where you live, the options will vary.
First, you want to identify which clinics are in your city or within driving distance. Certainly, some people choose to travel for treatment, and that is reasonable, depending on your situation. But if you are just starting out, looking in your own city within a close driving distance is a good place to start.
The outcomes for these clinics are reported on multiple websites, such as the CDC and the Society for Assisted Reproductive Technology, so information about their outcomes in a variety of different treatments should be readily available information to you.
I really cannot stress this enough: It is important to find a clinic that communicates effectively with you. We know our workday can be a bit unreliable; it can be chaotic, and there might be emergencies, so your clinic must be able to communicate with you effectively.
Will they only make phone calls and must they speak to you directly? Do they only use online portals? Do they respond to emails in a timely manner? They must be flexible. I encourage people to ask how the clinic communicates so that they can be sure they get the information they need in a timely fashion.
You will want to discuss finances. The clinics themselves can investigate your insurance, but you can also do that yourself to try to understand what benefits you have, if any. You may have benefits for therapy, you may have benefits for drugs, you may have no benefits for either, or you may have a one-time benefit.
I am currently working through my first pregnancy via a gestational carrier. Her insurance covers her pregnancy; my insurance covers nothing related to that. We had an insurance scare where she might lose her insurance, and the insurance that she would then get would not cover her pregnancy. There are a lot of different intricacies between the policies, so I definitely encourage you to look into that. The clinics can help you do that.
What types of payment strategies do they have? Do they have resources for reproductive loan services or fundraising? There are a variety of different things that can supplement this. So, being creative can be something that your clinic might have resources for.
Finally, some clinics, especially very busy ones, can have long waits on the order of months, six months, sometimes even out to a year. Time is important, so if this is something you might want to do, just getting on a list and doing your research in your homework. Reading a couple of chapters out of the book can be helpful to get the process going.
Sacopulos: Some important information there. As we finish our time together today, I want to ask about the adoption option. Can you talk a little bit about that, please?
Miller: Absolutely. Non-traditional family-building discussions are not complete without a visit to the adoption world. And so many people say “just adopt” when others are faced with fertility issues or the inability to conceive.
Adoption is, without a doubt, very meaningful. It is successful for many people, and I support them on that journey. I was on that journey for a year and a half myself. There is a reality to adoption that we should talk more frankly about: It comes with a long process, you have to be approved, and it can come with heartache.
Briefly, to be approved for adoption, you have to have an agency. So, you have to find one, vet one, sign a contract, and complete a home study, which is an evaluation that does a deep dive into your financial, psychological, and physical well-being to ensure that you can provide a stable home for an adopted child.
Someone comes into your home to inspect it and make sure that it is fit for a child. I understand all those steps in the process; however, it can feel very invasive. Also, you will need to make a profile about your family or about you if you’re single that is shared with birth mothers or birth parents. The process can take many months, so planning for that takes some time, some research, and some intention.
Sacopulos: That is good to know. I did not realize the process involved that. Thank you for that information.
Miller: My goal is to shed light on a topic that often remains in the dark and to let you know that you are not alone. If you are considering fertility treatments or adoptions, there are many options available, and pursuing them early will increase your chances for success. If you are interested in step-by-step introduction to navigating your fertility, please check out my book.
Sacopulos: Thank you so much for your time today. The book again is Navigating Your Fertility as a Woman in Medicine. The author is Dr. Jenna Miller. Dr. Miller, thank you so much for being on SoundPractice.
Miller: Thank you so much.
Sacopulos: My thanks to Jenna Miller; her willingness to step forward and discuss a difficult topic to help fellow physicians is an act of leadership and kindness. My thanks also to the American Association for Physician Leadership for making this podcast possible. Please join me next time on SoundPractice. We release a new episode every other Wednesday.