Is Delaying Childbearing During the First Few Years of a Career Worth It?

The first few years of residency and practice can be a challenge for most otolaryngologists, but especially for those who are considering starting a family. Some have opted to pause trying to get pregnant, while others have started their families, but at a cost of time and resources. There are reasons why the decision on what to do is a vital one.

A recent study in JAMA Network Open (2023. doi:10.1001/jamanetworkopen.2023.26192) showed that delaying pregnancy may account for higher rates of infertility among female doctors. The survey study of more than 1,000 female physicians found that although they fully understood that fertility declines with age, three-fourths of women physicians delayed childbearing and more than one-third experienced infertility. And a 2016 study in the Journal of Women’s Health reported that the prevalence of infertility among doctors was 24%, more than double that of the general population at 11% (J Womens Health (Larchmt). 2016. doi:10.1089/jwh.2015.5638.).

According to The American College of Obstetricians and Gynecologists (ACOG), female fertility decreases gradually but significantly at around age 32 and then more rapidly at around age 37, with both the quantity and quality of eggs declining (The American College of Obstetricians and Gynecologists Committee on Gynecologic Practice, Number 589. 2022). ACOG recommends that patients who wish to become pregnant become educated and aware of the effects that aging has on fertility, as well as the increased risk of pregnancy loss.

The Option of Egg Freezing

Christine Settoon, MD, would like to give birth someday. But as a 34-year-old pediatric otolaryngology fellow at Children’s Hospital in Philadelphia, her career goals and her hope to become a biological parent haven’t exactly been aligned.

“Once you step foot in medical school, and especially if you go into surgery, your next 10 years are basically mapped out for you,” she said. “You don’t have control over much, including whether you’ll be able to get pregnant if you want a baby.”

Once you step foot in medical school, and especially if you go into surgery, your next 10 years are basically mapped out for you. You don’t have control over much, including whether you’ll be able to get pregnant if you want a baby. — Christine Settoon, MD

Five years ago, as a resident, Dr. Settoon became very aware that her biological clock might soon be running out of time. “It’s hard knowing you have devoted your most fertile years to your career and when you’re ready to have a baby, those years might be gone,” she said. While doing her residency at LSU School of Medicine in New Orleans, Dr. Settoon heard about oocyte cryopreservation from a colleague and decided to visit a fertility specialist to learn more about the procedure of egg harvesting and preservation. She took an anti-Mullerian hormone (AMH) test to ascertain her remaining egg supply; the results of her test fell in the 20th percentile.

“I’m a Type A person and I freaked out,” she said. “I remember thinking, ‘I’ve never been in the 20th percentile in anything in my life.’” Her fertility specialist said if her AMH was at this level at 29 and she wanted to have a baby at 37, her chances would be very slim.

Dr. Settoon was very motivated to freeze her eggs but also concerned about the time the hormone injections, regular appointments, and egg retrieval would take away from her residency. And while some insurance covers infertility, Dr. Settoon wasn’t infertile and her procedure was considered elective, so she was also concerned about the out-of-pocket costs, which were estimated at around $12,000, if all went well. “I didn’t have $12,000,” she said. “I didn’t have $100.”

So, Dr. Settoon, the only daughter in a large family-oriented clan, and the only one who doesn’t yet have children, decided to ask her parents if they could help financially. “They are very traditional, and I assumed they wouldn’t be supportive of this,” she said, “so I was nervous.”

Thankfully, she was wrong. Her parents, seeing this as an investment in her future and perhaps an insurance policy for more grandchildren, couldn’t deposit the money into her bank account fast enough, calling it her “early inheritance.”

Costs and Concerns

For Christine Matthews, MD, a 30-year-old fourth year otolaryngology resident at the LSU School of Medicine in New Orleans, the decision to freeze her eggs last year during a research rotation was less fraught, as her health insurance covered the majority of the expenses.

“My out-of-pocket costs were significantly lower than the overall cost of the process, which made the decision easier,” she said. One of Dr. Matthews’ best friends from medical school is an OB/GYN resident who encouraged her before and during the process, knowing that female physicians are at a higher risk of having fertility issues and pregnancy loss.

Dr. Matthews, who has always envisioned herself having children, said she wants to do a one-year fellowship after residency and hopes to feel settled into her career before starting a family. This means she wouldn’t be ready to become pregnant until age 34 at the earliest. “Women’s fertility in general is hard to predict and you truly never know if you’ll struggle,” she said. “Freezing my eggs felt like a way that I could take some control over the situation.”

Having the time to give to egg harvesting and retrieval appointments can be another challenge for dues-paying, busy young otolaryngologists. Physician visits are every two days and include both imaging and lab work, not to mention nightly hormone injections that can wreak havoc on one’s emotions.

“Creating space for those appointments would be very difficult and seemingly impossible as a resident unless you were on a rotation like the one I was on or did the majority of the process over a vacation week,” Dr. Matthews said.

As for the injections, which need to be given around the same time each night, Dr. Matthews recalls having to scrub out of a late-night surgery once to do her injections in the operating room lounge from medications she had stashed in the refrigerator before scrubbing back in. Dr. Settoon gave herself an injection in a bathroom at the Superdome during an LSU national championship football game. “People were like, ‘What is that girl doing at the sink?’” she said.

The timing of Dr. Settoon’s egg retrieval was also during a less-busy-than-usual rotation that involved being in clinic just three days per week. “My program director, Laura Hetzler, MD, and my co-resident on that rotation were probably the only reason I could feasibly do it because they were so supportive,” she said.

Management Support

Dr. Hetzler, an otolaryngologist and facial plastic surgeon who is vice chair of the department of otolaryngology at the LSU School of Medicine and its residency program director, has two children of her own and was delighted that Dr. Settoon was being proactive about her fertility.

“We have to make the work environment more feasible for women of childbearing age,” Dr. Hetzler said. “I think a surgical residency is hard enough. I have plenty of colleagues who waited until after residency or fellowship and they had a hard time conceiving. Some of them still have not had children. I never want that to happen to any of the female surgeons if I could make it better for them.”

When Priya Krishna, MD, now an associate professor and co-director of the Loma Linda University Voice and Swallowing Center in Loma Linda, Calif., was a resident in the late 1990s, it was fairly early in the development of egg freezing technology. “Nobody was really talking about having it done and I had no idea how precipitously fertility drops from a woman’s mid to late twenties onward,” she said. “I wish I had this emphasized more in my training because I would have paid whatever I could to have frozen my eggs.”

Former chair of the AAO-HNS Section for Women in Otolaryngology from 2021 to 2022, Dr. Krishna thinks it’s wise that female residents are doing this now. From her own experience with infertility, she’s recommended freezing eggs even earlier than age 30. “The first dip in fertility happens around 27 years old and then again at around age 34, and fertility is pretty much gone by age 40 for most, although, of course, there are exceptions,” she said.

As keynote speaker for the inaugural Women in Surgery and Anesthesia Committee at her institution, Dr. Krishna made it a point to discuss the fertility risks associated with delaying pregnancy with the female interns present. Her advice: Freeze your eggs whether or not you think you want to be a mother because

if you change your mind all of your options will be available to you. “Our bodies do not stop aging, particularly the eggs,” she said.

Dr. Krishna also cares about exposing gender issues in the workplace and finding solutions to those inequities. To that end, she hosted a Women in Otolaryngology webinar last year titled, “Optimizing Physical Health and Navigating the Fertility World.” She works at an institution that she says is very family oriented, so male residents and faculty, whether they are fathers or not, seem to be very understanding of the challenges for women who are pregnant or battling with fertility issues at work.

Citing a body of research showing that stress impacts fertility and that the frequency of call can be linked to more complicated pregnancies, Dr. Krishna said, “It’s imperative that we support our female trainees and faculty because they’re assets to our institutions. It’s in our best interest and theirs for them to not have to struggle with these issues or deal with complicated or high-risk pregnancies.”

Dr. Krishna would like to see training programs pay for egg freezing, since these programs are aimed at women in their prime childbearing years and believes that adequate paid time off for maternity leave should be uniform among institutions. She would also like to see paternity leave not only offered but encouraged.

Support from Peers

Another participant in the webinar, Australia-based rhinologist and skull base surgeon Raewyn Campbell, MD, struggled to conceive for nearly two years during her residency before seeing an in vitro fertilization (IVF) specialist. She was in her 30s when she and her husband went through a battery of tests, including a laparoscopy and hysteroscopy, with no abnormalities detected. She did two cycles of IVF and miscarried before starting her fellowship. “I then saw a new IVF specialist when we moved to Auckland and did two more cycles,” she said. “Unfortunately, the first cycle resulted in a miscarriage of identical twins that occurred while I was operating, despite the fact that I was being as careful as I could be.” She ended up needing a dilation and curettage procedure from the experience.

Dr. Campbell ultimately became pregnant, despite challenges that involved three weeks of bedrest, and delivered a son who is now nine years old. When her son was 10 months old, however, she and her husband embarked on having a second child, a journey that involved another miscarriage and multiple failed IVF cycles while still performing surgery. “I ultimately traveled to a fertility center in San Diego and fortunately conceived my daughter, who is now six,” she said. “We never found the cause for our infertility despite a thorough investigation and no initial indications we would ever struggle with fertility.”

Dr. Campbell said the support of her colleagues along the way meant the world to her, but she also knows that nearly 20% of pregnant women had negative comments made about them by their peers and 94% wished for greater mentorship on balancing work and parenthood (IFF Research Ltd. Pregnancy and Maternity-Related Discrimination and Disadvantage: Summary of Key Findings. 2016). “By being open with my situation, I hope that other women and men going through this will feel that they can reach out and that we can eliminate any sense that this topic is taboo or a source of shame,” she said. “Even if they choose not to reach out, as this is an extremely personal journey, I feel strongly that it’s important that they know that they aren’t alone.”  

Renée Bacher is a freelance medical writer based in Louisiana.