- One in four female physicians is diagnosed with infertility.
- There are several ways to combat the increased prevalence of infertility among female physicians, such as making this statistic more familiar to the medical community.
- Increased education among current medical students and residents will better prepare the next generation of female physicians to combat this obstacle and consider earlier intervention.
- Expensive infertility treatment can become unmanageable without insurance coverage.
- Infertility insurance coverage has become more customary in recent years, and state mandates regarding infertility coverage laws continue to be established.
- Offering infertility coverage benefits leads to greater employee satisfaction and less turnover without significantly increasing medical plan costs.
Female physicians have a two times greater incidence of infertility compared to the general population with one in four receiving such a diagnosis (Stentz et al. 2016); however, this grim statistic is not widely recognised or understood.
Medical education is a long and arduous process that interferes with a woman’s most fertile years. The Association of American Medical Colleges (AAMC) notes the average age at matriculation into medical school is 24, which corresponds to the beginning of declining fertility that can start as young as 25-30 before a substantial decrease around 35 (Vander Borght and Wyns 2018). Concurrently, a female medical student or resident may not feel prepared to become pregnant and raise a child until she has completed her education and training, full of intense study demands, clinical rotations, and little flexibility. Because of these commitments, many delay childbearing; in fact, most female physicians have their first child just before completing residency, 7.4 years later than the general population (Stentz et al. 2016). Most physicians complete their postgraduate training at an average age of 32 years old, and infertile physicians receive their formal diagnosis at an average age of 33 (Stentz et al. 2016). This leaves many female physicians struggling with infertility while nearing the advanced maternal age, sometimes called geriatric maternal age, of 35, when the odds of a successful pregnancy significantly worsen. While all this data may be unsettling, the U.S. is far from powerless in keeping its female physicians from becoming “involuntarily childless” due to their career choice (Kemkes-Grottenthaler 2003).
There are several opportunities to help combat female physician infertility in the U.S.: heightened awareness, increased education, and widespread infertility insurance coverage. Young female medical students need to be made aware of this increased prevalence and educated about infertility more generally. This includes what a woman can and cannot do to control her fertility, what treatment options may look like, and information about fertility preservation such as cryopreservation or egg-freezing (Marshall et al. 2020). In a survey of female physicians previously diagnosed as infertile, retrospectively, 17% would have cryopreserved their eggs (Stentz et al. 2016). It would be impossible, however, to make such a decision without being aware that these options exist. Reproductive health and infertility are existing elements of early medical school curriculum; it would be seamless yet impactful to incorporate statistical data on infertility’s increased prevalence among female physicians. Nearly half of the respondents were either “quite a bit” or “very much” surprised by their infertility diagnosis (Stentz et al. 2016). Earlier recognition of the potential for infertility along with an action plan and insurance coverage could have significant impact on management.
Beyond the emotional and physical tolls that infertility evaluation and treatment can carry, the financial toll is daunting. A 2011 study on the costs of infertility treatments noted the median costs per person ranged from $1,182 for those requiring medication only, up to $38,015 for IVF-donor egg users (Katz et al. 2011). Moreover, these numbers become higher when success is considered: $5,894 and $72,642, respectively (Katz et al. 2011). With these costs being additional to those associated with pregnancy once achieved, one might think that insurance coverage for the evaluation and treatment of infertility should be required. Luckily, mandated infertility coverage in the U.S. began in the 1980s (RESOLVE.org 2021). In the past five years, five additional states have passed infertility coverage laws, bringing the total number of states with an infertility coverage law to twenty (RESOLVE.org 2022). While these laws are certainly a step in the right direction, they vary from state to state with many exemptions, specific eligibility criteria, and hidden caveats that significantly limit those who effectively receive mandated coverage for their infertility (RESOLVE.org 2022). Ultimately, it is up to individual employers to support their employees by offering such health benefits.
One large health system in New York, Northwell Health, recognised that coverage for infertility treatment and management would be an employee recruitment and retention tool. Vice President of Physician Recruitment at Northwell Health in New York, Ms Judith Heller, gave a unique perspective on the progress that has been made during her 14 years with Northwell and explained the pivotal role that comprehensive infertility benefits has played for Northwell’s employees. She recognised that many potential employees either completely avoided or were hesitant to ask about infertility coverage, so she created a one-page document outlining the benefits that Northwell offers. These currently include artificial insemination, medications, surrogacy, and different assisted reproductive technologies (ARTs) such as in-vitro fertilisation (IVF). Creating an incredibly supportive environment where fertility is facilitated and pregnancy is celebrated has led to an increase in recruitment and retention of female physicians. “Such a work environment leads to relationships of trust and loyalty, with happier employees who feel better supported”, shares Ms Heller.
Infertility insurance coverage helps combat the issue of “involuntarily childless” female physicians in the U.S. It also leads to more satisfied employees with less turnover (Kemkes-Grottenthaler 2003; RESOLVE.org 2021; 2022), and offering such benefits does not carry any significant increase in medical plan costs (RESOLVE.org 2021). In a 2016 survey of 700 employees undergoing rounds of IVF, those with employer-provided IVF benefits were much more satisfied with their employer when compared to those without such benefits (RESOLVE.org 2022). They were less likely to miss work, more likely to recommend their employer to job seekers, and felt more listened to and cared for by their employer (RESOLVE.org, 2022). A similar survey in 2017 found that employees who underwent insurance-covered IVF were more likely to work harder and retain their job for longer (RESOLVE.org 2022). With such a high benefit-cost ratio, it is no surprise that more and more companies have adopted similar benefits, including additional family-building benefits such as adoption or fostering. Since 2019, there has been an 8% increase per year in the number of large companies that newly offered or expanded their infertility or family-building benefits (FertilityIQ 2022). At Northwell, infertility coverage became a part of the benefits offered after their annual Employee Engagement Survey. While other employers are beginning to listen to the needs of their employees and take action to support them, health insurance for infertility is still not consistently offered.
While the statistical evidence regarding infertility insurance coverage seems to be trending in the right direction, there is more work to be done to support and treat infertility among female physicians. After conquering their infertility battle, female physicians often face additional difficulties; there are substantial increases in complications such as gestational hypertension, preterm labour, and placental abruption among female physicians (Stentz 2016; Finch 2003; Grunebaum et al. 1987; Rangel et al. 2021). Increasing research into the aetiology and management of these pregnancy-related conditions may lead to changes in training and work-life balance. Inclusion of adoption benefits would be an additional means of support for physicians seeking to start a family. Currently, only 20% of companies that offer fertility coverage also offer foster or adoption benefits (FertilityIQ 2022). Of those that offer such benefits, the average level of coverage is less than 25% of that offered for fertility (RESOLVE.org 2022). While treatments to become pregnant can be decidedly beneficial, millions of children are already born and in need of loving homes across the globe, and adoption may be a viable alternative. By allowing infertility coverage benefits to grow and evolve while education efforts are initiated and further research is funded, the odds for the next generation of female physicians to become successful in both their career and parenthood improve.
Due to the conflicting timing of medical education with maximum fertility, many female physicians may have unwittingly sacrificed their fertility for the sake of their passion for medicine. Unfortunately, female medical students and residents will continue to struggle with the balance between their chosen career path and their personal life due to the time and energy commitment that their education requires. The next generation of physicians must be made aware of the many fertility treatment options earlier on and better educated on this issue, and it is imperative that this awareness and education penetrates U.S. medical schools. Unfortunately, a recent study revealed that there is inadequate coverage and large limitations to fertility benefits at the majority of top medical schools across the country (Hoang et al. 2022); this speaks to the lack of attention this issue is receiving where it is needed most. As the number of female medical students has climbed to roughly 50% in recent years, the percentage of female physicians in the workforce is expected to increase as well (Boyle 2019; Boyle 2021). With this rise, a greater number of our nation’s female physicians will face infertility struggles. Education and continued strides on both a national, legal level as well as within individual businesses and institutions regarding infertility coverage will contribute to bettering female physicians’ odds of successful pregnancies. Becoming a physician should not preclude women from growing their families. Such dedication to serving others deserves better support, education, and insurance coverage for the future of U.S. female physicians and their families.
Conflict of Interest