What Every Woman Should Know About Her Fertility

Today Dr. Sabrina Gerkowicz, a reproductive endocrinologist (aka fertility doctor) shares with us some very important findings and statistics about #physicianinfertility as well as what a fertility workup looks like, who should have one, and 5 things you MUST know!

Infertility, defined as failure to achieve pregnancy within 12 months of unprotected intercourse or donor inseminations in women younger than 35 years or within 6 months in women older than 35 years, affects up to 10-15% of couples.

However, recent studies have found that this incidence can be even higher in women in medicine.

An article recently published in JAMA Surgery (2019), by Matilda Anderson, MBBS, MPH and Rose H. Goldman, MD, MPH addressed this very topic. “Studies comparing surgeons with the general population show increased rates of infertility and pregnancy complications, including conditions affecting both the mother and fetus, such as spontaneous abortion, preterm delivery, growth restriction, and congenital abnormalities.” While most of the attributed blame for these findings has focused on older age and demanding working conditions of pregnant surgeons [or one might extrapolate this to physicians in general]; the authors note that “there are reproductive hazards present in the operating room that might also be contributing.” Some of these relevant hazards listed in the paper include radiation, surgical smoke, working conditions, sharps injury, anesthetic gases, and intra-operative use of toxic agents to name a few.

Aghajanova et al. (2017) found that 29% of their survey cohort of OBGYN residents interested in fertility, experienced infertility of some degree.

In a study by Stentz et al. (2016), 600 female physicians were surveyed and of the 54.5% that responded, nearly one quarter (24.1%) who had attempted conception were diagnosed with infertility, with an average age at diagnosis of 33.7 years. Among those with infertility, 29.3% reported diminished ovarian reserve.

Pham et al. (2014), conducted a study examining birth trends and factors affecting childbearing among thoracic surgeons. A total of 113 physicians responded (88 women, 25 men); and 69% (61 of 88) of women and 88% (22 of 25) of men who desired children, 98% (60 of 61) of these women and 50% (11 of 22) of these men delayed pregnancy (p < 0.0001). Eighty-two percent (72 of 88) of women versus 60% (15 of 25) of men felt their career would be adversely affected, with 6% (54 of 88) of women and 16% (4 of 25) of men reporting that pregnancy would be viewed “unfavorably” among peers (p < 0.03 and p < 0.0001, respectively). In women of childbearing age, 28% (15 of 54) utilized assisted reproductive technology (national average ~12%, p < 0.0002). This paper found that the total fertility rate in this cohort was 0.6 ± 0.2 children per woman whereas the national rate was 1.9. The average age at first-childbirth was 34.3 ± 0.7 years, while the national norm was 25.4.

Turner at al. (2012) surveyed women members of the Association for Women Surgeons or the American College of Surgeons who graduated from medical school and practice general surgery or a general surgery subspecialty. They concluded that the number of women general surgeons becoming pregnant during training has increased in recent years; however, substantial negative bias persists. Although the overall magnitude of perceived negative attitudes is greater among male peers than female peers, and among faculty more so than peers. Even women residents held negative views of pregnancy among their colleagues during training. More than half of all women surgeons delay childbearing until they are in independent practice, or until post-training. Surgical residents and faculty of both sexes exerted negative influences with regard to consideration of childbearing. THIS IS A HUGE PROBLEM.

These are by no means all the publications on this topic, but the notably higher incidence or reported numbers regarding physicians and fertility is very eye opening. What is scary is that most physicians are not aware of these numbers, and/or even if they are, the persistent stigma and work-related concerns many physicians feel about getting pregnant during their training or early careers are ALL TOO REAL!

More and more studies are making their way into the literature about physicians of all specialties continuing to delay or postpone starting a family during medical training or in medical careers (and in many careers really) for a slew of reasons; however, because the system is not accepting, supportive, or accommodating should NOT be one of them.

In an article recently published in JAMA Network (2020) by Bridget M. Kuehn however; my heart felt a little flutter of hope. This article highlights some wonderful people at various medical institutions that are making HUGE strides to change the culture in medicine to one that supports trainees or people in medicine during pregnancy and after.

Michael Gisondi, MD and June Gordon, MD of Stanford University “teamed up to devise a plan for new parents in medical training; a return-to-work policy for all new parents, including those who had a child born into their family, used a surrogate, adopted, or fostered.”

“Under the policy, new parents can choose to forgo overnight shifts, unscheduled call, or having more than 3 shifts in a row for 6 weeks after their return from parental leave. For 4 weeks before their estimated delivery date, pregnant residents are exempt from overnight shifts, unscheduled call, and more than 3 shifts in a row. The policy also covers parental leave, lactation, and a comprehensive list of other resources for new parents.” Sarah Shubeck, MD, MS, chief resident in the Department of Surgery at the University of Michigan helped start a policy to help make it easier and more accessible to pump, especially in surgical specialties. “It's recognizing that we should prioritize the health of our workforce in addition to the health of our patients,” she said. “The biggest change, Shubeck said, has not been the logistics but rather a cultural shift that recognizes lactation as a health need, not an extra break.” As of July 1, ACGME will mandate that all programs have “clean and private facilities for lactation that have refrigeration capabilities, with proximity appropriate for safe patient care,” as part of its common program requirements. I highly encouraged you all to read the full article if you are interested for full details.

There is one additional reason why all of this matters so much, for everyone.

In 2019, the New York Times reported that the rate of births dropped again in 2018 for the fourth consecutive year, according to new data from the National Center for Health Statistics, “extending a lengthy decline as women wait until they are older to have children.” In addition, “there were 59.1 births for every 1,000 women of childbearing age in the country last year, a record low.” The rate was down two percent from 2017, and “has fallen by about 15 percent since 2007.”

So, what is the main reason behind all these citations, numbers and facts?

This information is NOT meant to scare you, but rather the opposite effect is desired. KNOWLEDGE IS POWER, and the sooner we learn the better! One of the most heartbreaking things to hear as a Reproductive Endocrinology and Infertility physician is a patient saying “they wish they saw us sooner,” “they wish they knew,” or “they wish they had this conversation with us sooner.” We are also all so focused on our education, our careers, and taking care of our patients and others – that we often do so at the expense or neglect of ourselves. We can only act in the present, and it is always better to get the information now to help guide you make the right decisions for you. This is a call to action – both for awareness and to urge us to all prioritize self-care as well, and this includes our fertility!

So when and why should I have a fertility work up?

A fertility evaluation should not be viewed as a scary thing – it empowers you! You can’t take action if you are in the dark about your reproductive and gynecologic health. You also don’t have to have one, you just need to be informed so you can make that decision for yourself.

So, whether it is something you do proactively (have not yet tried to get pregnant), if you are planning to start trying, or are having difficulty getting pregnant – the evaluation is the same (although it can be more limited for the first group based on informed decision).

The American Society for Reproductive Medicine (ASRM) and the American College of Obstetricians and Gynecologists (ACOG) recommend that an infertility evaluation should be offered to any patient who by definition has infertility or is at high risk of infertility. Women older than 35 years should receive an expedited evaluation and treatment after 6 months of failed attempts to become pregnant or earlier, if clinically indicated. In women older than 40 years, more immediate evaluation and treatment are warranted. If a woman has a condition known to cause infertility (like endometriosis, irregular menstrual cycles, PCOS, two or more prior miscarriages, suspected male infertility, particular genetic or family history etc.), the obstetrician–gynecologist should offer or refer for immediate evaluation.

So, what can I expect during a fertility work up?

As with everything, your first visit will start with a very thorough history. Everything including medical, surgical, family, and social history, as well as current medications, and of course a detailed reproductive history are very important.

Your next steps will include an evaluation of the following:

Ovarian reserve

This is evaluated by ultrasound and blood work done between cycle day 2-5 typically – so you will likely still be menstruating at this time. The transvaginal ultrasound will evaluate the ovary, measure ovarian size, and an antral follicle count (AFC). An AFC is the number of follicles (i.e. fluid filled sacs in which an egg develops) that are available on the ovaries to respond to either pituitary or exogenous stimulation that month, ~10-15 is typically considered normal). The blood tests include serum FSH, LH, and estradiol (E2) and these will evaluate the hypothalamic-pituitary-gonadal axis and see how it is functioning.

The last test is serum Anti-Müllerian hormone or AMH. This reflects the “total number” of pre-antral and antral follicles in your body – your value is interpreted relative to the average of other women your age. A few important things to know about AMH are: it can be temporarily suppressed by prolonged combined oral contraceptive therapy, so it might be wise to get this (and the hormones above) tested after a 1-3 month “wash-out period” where you are off of OCPs (be mindful to prevent pregnancy during those months if you are not trying to conceive). Also, the data for AMH values tends to come from studies conducted amongst infertility patients, so these numbers need to be interpreted somewhat differently in women who do not meet the diagnostic criteria for infertility. It is more applicable or reflective of how well your ovaries would respond to exogenous stimulation (i.e. fertility medications) instead of your chance of conceiving (naturally or with assistance) – big difference! This is something you would discuss in more detail with your fertility physician if applicable.

Uterine anatomy

The primary tools for this includes a transvaginal ultrasound and/or saline infused sonogram (SIS) to look for any fibroids, or other uterine findings. A saline infused sonogram helps us evaluate the uterine cavity more thoroughly in 2D and 3D (for submucosal fibroids, polyps, uterine anomalies etc.). It is a combination of a transvaginal ultrasound with simultaneous slow infusion of saline via a very small catheter into the uterus. You might feel very small menstrual like cramps with this procedure (if any).

Fallopian tubes

The tubal evaluation focuses on determining patency and tubal shape via a hysterosalpingogram (HSG). This is a quick procedure with a slow infusion of dye through a very small catheter into the uterus (just like the SIS) while capturing a few X-ray (brief fluoroscopy) images. A small C-arm is often used and positioned just over the pelvis to capture these images. You might feel very small menstrual like cramps with this procedure (if any), for some women more so than the SIS.

General health and endocrine factors as indicated

This section may vary for each individual and by fertility center, but some of the tests you could expect include evaluation of endocrine (thyroid function – TSH and free T4; prolactin); metabolic (hemoglobin A1c, CMP, insulin…); and or hematologic systems (hemoglobin electrophoresis etc.) as well as anything else that might be applicable based on your history.

Pre-conception testing

This section includes all the tests that would be recommended in the first trimester of pregnancy, as well as some other very important pre-conception tests. Carrier screening panels are wonderful tools available now that allow for screening of intended parents to check for carrier status of over 200+ mostly autosomal recessive traits (only a concern if both partners are carriers of the same disease - i.e. cystic fibrosis, then further genetic counseling should be offered and options like in vitro fertilization with genetic mutation testing of the embryos can be discussed). Other standard tests include, CBC, ABO/Rh, STI screening, rubella and varicella immunity etc.

Semen analysis

Male factor is a cause of infertility in 30–40% of couples; therefore, a basic medical history and evaluation of the male partner is really important do to simultaneously with the female workup.

What would this work up look like for me, time-wise?

After you have your new patient visit, typically you would wait until next menstrual cycle 🡪 then work up can begin. On cycle day 1 (CD 1), which is considered the first day of full menstrual flow (where you need a pad or tampon, not just spotting), you would call your fertility office to schedule the following appointments (up to 3-4 appointments total) on these days:

1. CD 2-5 Pelvic ultrasound and all blood work

2. CD 5-12 Saline infused ultrasound (SIS)

3. CD 5-12 Hysterosalpingogram (HSG)

Semen analysis and blood work for your partner (if applicable) can be done any time, but plan 2-3 days of abstinence prior to having the semen analysis to allow for optimal interpretation of results. Remember to do this a few weeks before the follow up so your fertility doctor will have the results available to share with you

1. Follow up with your MD usually about ~2-3 weeks after all testing has been completed and results are back. At that visit, everything will be reviewed with you in detail AND treatment recommendations will be shared.

Broadly speaking, infertility can be broken down into the following categories: diminished ovarian reserve (~30%), ovulatory dysfunction (15%), tubal factor (14%), uterine factor (5%), male factor (~30+%), endometriosis (8%), unexplained (all elements of the workup have resulted as “normal” ~15-30%), or any combination of these factors (~30%; hence these #s do not add up to 100%).

All these details and steps… it’s a lot.

There can be a number of appointments at first. Please don’t be intimidated or frustrated by this. You can also spread them out over more than one menstrual cycle if needed for scheduling or other reasons. Also remember that not all steps may apply to you, and your fertility office will definitely try to make it work as much as possible for you (schedule-wise). All this information allows us to get a very detailed evaluation from the start, so when we meet again, we can come up with the best recommendations together - specific to your situation, goals, and timeline. It makes sense to be thorough on the front end, but at the same time it’s important to know that it is not possible to “check for everything” – nor is that the right thing to do. But the steps outlined above will give us a lot of information to help you get started!

Some key things to remember with all of this…

#1 - There is NO “RIGHT TIME…” Right time to get pregnant, right time to start trying etc.… the list goes on. In medicine (and for everyone), training and life will always keep us VERY busy, our roles and responsibilities continue to change, there will always be more board exams, life will also throw us some curve balls (#COVID). The one constant here is that you have one life to live. Do what feels right to you, and if that means putting your fertility on the back burner for a little while, that’s ok. However; getting an earlier evaluation so you leave yourself options, is very wise, when you are ready. The one thing we can’t do is turn back the clock.

#2 - This is a VERY PERSONAL choice – everyone is different. It can be hard to look around and not feel stressed out as a result – especially when you compare yourself to others. That’s all the more reason to get YOUR numbers, that way you can make the best decision for you! Remember everyone is in different chapter of their life, you also don’t know their specifics. Run your race. Celebrate the joys, victories, and success of your family members, friends, and colleagues. Yours WILL come too.

#3 - You ARE NOT ALONE. Infertility can make you feel this way, but it is not true! WE are here for you and understand. We are on your team. The online community has grown so much and there are so many brave people who have gone through the same thing who share their stories and come together, forming invaluable networks. There are wonderful organizations and resources that we can also share with you.

#4 – Do NOT lose hope. This process might sound a little intimidating and/or daunting. But this is what we do. We specialized and trained for this, and we be with you and help guide you all along the way. Fertility centers and their entire teams are all there to help you, from beginning to the end.

#5 – Let’s talk about it! This topic should not be taboo! We CAN have both – physicians can be happy & fulfilled at work and on the personal/home front … the two are not mutually exclusive.

I hope this has helped to both: de-mystify the process and walk you through how we get the facts. Remember, knowledge gives you power and only you can make decisions about your health, including your fertility. We are always here to help!

Sending lots of positivity and support your way,

Sabrina Gerkowicz, MD

#PhysicianInfertility

#InfertilityAwareness

#NIAW

#SayTheFWord

#ThisIsWhatInfertilityLooksLike

#1in4

#DoctorswithInfertility