Pregnancy, infertility, and medical training: A hidden crisis

Stephanie Pearson, MD

It was 2 a.m. on December 6th, 2006. I was on call, delivering a set of vaginal twins—something I normally loved doing. But this morning was different. At 38 weeks and 1 day pregnant, I was accustomed to my son, Jake's, nightly acrobatics, his predictable 2 a.m. wake-up calls from inside my belly. As I focused on the delivery, I realized he wasn't moving.

I began poking my stomach, trying to get him to respond. I felt something, but not enough. I knew that after this delivery, I'd need to get to the ultrasound machine.

The delivery was successful—healthy babies, recovering mother—but I was panicking inside. I went straight to the ultrasound and performed the scan myself. Jake was breech, and there was almost no amniotic fluid. No 2cm pocket anywhere. I made my phone vibrate against my stomach to stimulate him. He passed the rest of the biophysical profile, but with oligohydramnios, I should have been delivered immediately.

I called one of my partners. He recommended IV fluids and monitoring. As a new attending, without the self-confidence I have now, I didn't want to rock the boat. The nurses hooked me up to an IV, and I stayed connected until another patient was ready to deliver. Then my nurse capped the IV, disconnected me, and I went to perform another vaginal delivery. I thought surely my partners would come in at shift change and deliver me.

They didn't.

I had a full day of patients scheduled. The non-stress test was beautiful, I'll admit, and I let my partners talk me into seeing my patients and getting retested at lunch. I would never have agreed to that plan for any of my patients. At lunchtime, I returned to the labor floor for another NST and ultrasound. Beautiful strip, still minimal fluid. Delivery? Still no.

I saw the rest of my patients for the day. I wasn't delivered until 10:18 p.m.

Does that sound right to you?

My son is 18 years old now, and I think about his delivery frequently. Why wasn't I delivered earlier? How did I let that happen? What would I have done if something tragic had occurred? What would my husband have thought? When I started discussing this experience with colleagues, I discovered my story wasn't unique. The expectations placed on pregnant residents and attendings differ dramatically from those of non-physicians.

This realization made me think more broadly about pregnancy and family planning in medicine.

The scope of the problem

The statistics are sobering. Approximately 3-quarters of female physicians (75.6%) report delaying family planning due to the demands of medical school, residency, and early practice. In a 2023 nationwide survey of 1,056 US female physicians, 798 respondents acknowledged postponing pregnancy for career reasons. Nearly half (47%) later passed up promotions or reduced their hours to accommodate parenthood.¹

The primary deterrents are built into our training structure: long, inflexible schedules and sleep-disrupting call hours. A 2024 review of 4,533 physicians showed that 72.9% cited schedule demands and 61.5% cited excessive work hours as reasons for delaying starting a family. The same study flagged insomnia as a significant fertility risk factor.²

The psychological barriers are equally daunting. Women residents who believe pregnancy threatens fellowship opportunities, leads to stigmatization by peers and superiors, and extends training are twice as likely to postpone childbearing. Institutional culture matters too—programs led by women faculty are perceived as markedly more supportive, yet only 8% of trainees report ever receiving formal counseling about the biological costs of waiting.²

The biological reality

Biology doesn't wait for career milestones. The fertility statistics are unforgiving: there's a sharp uptick in miscarriages after age 35, and obstetric complications increase steadily with maternal age.

Natural fertility declines steeply in 5-year increments after age 30. North American pre-conception data shows the fecundability ratio (relative chance of conception per cycle compared to women aged 21-24) dropping to 0.87 at 31-33 years, 0.82 at 34-36 years, plunging to 0.60 at 37-39 years, and 0.40 at 40-45 years. National data confirms this biological drift: impaired fecundity already affects 14% of women aged 30-34, 15% at 35-39 years, and 16% at 40-44 years.³

The consequences escalate quickly. Clinically recognized miscarriage rates rise from 20% at age 35 to 40% at 40 and an alarming 80% by 45.⁴ Gestational diabetes risk shows odds ratios of 1.69 (ages 30-34), 2.73 (35-39), and 3.54-4.86 (≥40) compared to the 25-29 reference group.⁵ Preeclampsia risk climbs in lockstep to 1.36 times higher for ages 35-39 and 1.83 times higher for 40-44 years.⁵

Delivery outcomes reflect these medical realities. U.S. cesarean rates jump from 33.9% (ages 30-34) to 40.1% (35-39) and 48% for women ≥40. The stillbirth risk between 37-41 weeks increases from 1 in 382 ongoing pregnancies at ages 35-39 to 1 in 267 at ≥40, equating to 10.1 per 1,000 births for ages 40-44.⁶

Each 5-year delay after 30 brings measurable drops in fertility and step-changes in obstetric morbidity—a vital context for physicians considering delayed parenthood.

The training environment: A perfect storm

Residency and fellowship create environments that simultaneously disrupt biological fertility and discourage pregnancy. Weekly duty hours routinely exceed 60-80 hours, including overnight calls, producing chronic circadian misalignment. Research shows that working two or more night shifts per week raises miscarriage risk by 32%, and recent meta-analyses confirm links between night-shift work and both miscarriage and preterm delivery in health care workers.⁷

For physicians in certain specialties, additional hazards compound the risk. Prolonged standing in operating rooms, plus exposure to ionizing radiation, anesthetic gases, and cytotoxic drugs, create teratogenic stressors that occupational reviews specifically flag for female physicians.

The physiologic strain appears in fertility data. A 2023 nationwide survey found that 75% of women physicians intentionally delayed pregnancy, and 36.8% ultimately experienced infertility. Female surgeons have pregnancy-loss rates more than twice that of the general population, with operating more than 12 hours per week independently predicting obstetric complications.¹

Cultural factors amplify these risks. Among 5,692 U.S. surgical residents surveyed in 2024, 61% of mothers reported pregnancy-related mistreatment and feared fellowship or promotion penalties. Only one in five faculty members says their programs provide clear, supportive policies for pregnant trainees.⁸

These physiologic, environmental, and cultural hazards create conditions that push many trainees to postpone childbearing until the very years when fertility is declining and pregnancy complications are at risk of increasing.

The cost of waiting

When physicians finally try to conceive, infertility takes both financial and emotional tolls. A single assisted reproductive technology cycle can drain resources long before a baby—or even a viable pregnancy—is achieved.

In 2024, U.S. clinics charge $14,000-$20,000 for a base IVF cycle, plus $3,000-$6,000 in injectable medications. All-inclusive, bills cluster around $23,000 per attempt when genetic testing and cryopreservation are included. Because 29 states have no infertility-coverage statutes and 63% of covered workers are in self-funded ERISA plans that bypass state mandates, most physicians pay these figures out of pocket.

Money represents only part of the burden. Prospective studies show couples devote 125 hours (approximately 16 workdays) across 18 months to fertility care—142 hours if they advance to cycle-based treatments like IVF. For trainees, these hours translate into missed cases, depleted vacation time, and additional childcare costs on top of five-figure medical bills.⁹

The emotional stakes escalate with every birthday and every failed cycle. In fresh-embryo IVF, miscarriage rates double from 15% in women under 30 to 30% at age 38, then soar to 55% at ages 40-44. Cohort data show a 52% miscarriage rate for women ≥40 on second attempts, meaning half of "positive" cycles end in loss.¹⁰ Each failed transfer resets the financial meter while compounding grief, anxiety, and self-blame. Global meta-analyses report that women with infertility face a 60% higher risk of clinically significant psychological distress than their fertile peers.¹¹

The insurance trap

These challenges are compounded by disability insurance complications. Insurance carriers find multiple reasons to exclude pregnancy from coverage, and women already pay twice as much as men for disability insurance, partly due to pregnancy-related claims.

If you've had a miscarriage within twelve months of applying, pregnancy won't be covered until you complete a healthy pregnancy with normal delivery and postpartum course. Any documented infertility history leads to the exclusion of both infertility treatments and pregnancy-related disabilities. Insurers view infertility workups, ART cycles, and pregnancy loss history as red-flag pre-existing conditions triggering permanent exclusion riders.

The underwriting logic is stark: industry data shows pregnancy and childbirth account for 22% of all private short-term disability claims and about 10% of long-term claims.¹² Any chart note documenting recurrent miscarriage, failed IVF cycles, or even initial infertility consultations can result in "pregnancy exclusion" riders that bar benefits for complications like gestational diabetes, postpartum cardiomyopathy, etc.

The practical message is clear: to secure comprehensive disability coverage, trainees should apply before infertility evaluations begin and long before pregnancy. Once loss or treatment appears in medical records, the window for full protection often closes.

Solutions: A 3-pronged Approach

Institutional reform

Institution-level fixes must start by acknowledging that delayed childbearing and pregnancy complications are workplace hazards, not just personal choices. Residency and fellowship programs can adopt a three-pillar approach:

Structural flexibility: Compressible rotations, shift trading, and protected "fertility leave" days, which function like academic leave for board exams.

Benefit parity: Mandating infertility coverage (egg freezing, diagnostic workups, IVF, pregnancy-loss counseling) in graduate medical education health plans and bargaining for supplemental disability policies without pregnancy exclusion riders.

Safety standards: Radiation shields, formal exemption from prolonged standing after the first trimester, and duty-hour limits that cap consecutive night shifts to reduce miscarriage risk.

Accreditation bodies can give these initiatives teeth by tying them to program-review scores. At the same time, hospital HR can add on-site childcare and phased-return policies that convert "all-or-nothing" maternity leave into graduated re-entry.

Interpersonal changes are equally critical: training leaders should model transparent family-planning conversations, pair junior physicians with mentors who have navigated pregnancy or infertility, and include male allies in workshops so parental-leave burdens don't fall solely on women colleagues.

Individual planning

Physicians can regain agency through deliberate planning and financial preparation. Early in residency, map a personal fertility timeline—basic AMH testing or egg-freezing consultation by PGY-2, target conception windows, and contingency plans for fellowship overlap.

Secure own-occupation disability insurance before any infertility labs, pregnancy complications, or ART cycles appear in your chart. Once documented, most carriers add pregnancy-related exclusion riders or surcharges.

Build an emergency fund covering at least one full IVF cycle ($20,000-$25,000) plus six months of living expenses. Set automatic transfers so the fund grows during training.

Finally, cultivate a support network—partner, co-residents, and mental health professionals—scheduled into the same calendar that holds OR cases and exams. This normalizes seeking help and prevents the emotional isolation that often shadows infertility and pregnancy loss.

Cultural change

The most profound changes require shifting medical culture to recognize that supporting physician families strengthens the profession. This means moving beyond lip service to create environments where pregnancy and parenthood are genuinely supported, not merely tolerated.

Moving forward

Institution-wide reforms, culture shifts, and personal financial planning create a safety net that allows physicians to pursue both professional and family goals without sacrificing health or income security. The story I told at the beginning—of a pregnant physician receiving substandard care because of professional expectations—should never happen again.

We train physicians to heal others. It's time we created training environments that don't sacrifice our health and families in the process. The next generation of physicians deserves better, and so do their future patients, who will benefit from physicians who haven't had to choose between career and family.

References:

1. Bakkensen JB, Smith KS, Cheung EO, et al. Childbearing, Infertility, and Career Trajectories Among Women in Medicine. JAMA Netw Open. 2023;6(7):e2326192. Published 2023 Jul 3. doi:10.1001/jamanetworkopen.2023.26192
2. Henning G, Agolli A, Henning S, Murphy S. Pregnancy challenges and outcomes among female physicians. Discoveries (Craiova). 2024;12(3):e192. Published 2024 Sep 30. doi:10.15190/d.2024.11
3. CDC. Key Statistics from the National Survey of Family Growth – I Listing. CDC National Center for Health Statistics. Accessed June 6, 2025. https://www.cdc.gov/nchs/nsfg/key_statistics/i.htm
4. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin No. 200: Early Pregnancy Loss. Obstet Gynecol. 2018;132(5):e197-e207. doi:10.1097/AOG.0000000000002899
5. Li Y, Ren X, He L, Li J, Zhang S, Chen W. Maternal age and the risk of gestational diabetes mellitus: A systematic review and meta-analysis of over 120 million participants. Diabetes Res Clin Pract. 2020;162:108044. doi:10.1016/j.diabres.2020.108044
6. Dekker, Rebecca. Evidence-Based Birth: Evidence on Pregnancy at Age 35 and Older. Evidence-Based Birth. Accessed June 6, 2025. https://evidencebasedbirth.com/wp-content/uploads/2021/06/AMA-Handout-v2021.pdf
7. Hammer PEC, Flachs EM, Garde AH, Begtrup LM, Bultmann U, Madsen IEH, et al. “Night shiftwork and the risk of miscarriage: a prospective register-based cohort study.” Occupational and Environmental Medicine (a BMJ journal). 2019; 76(5):302-308.
8. Li RD, Janczewski LM, Eng JS, et al. Pregnancy and Parenthood Among US Surgical Residents. JAMA Surg. 2024;159(10):1127-1137. doi:10.1001/jamasurg.2024.2399
9. Wu AK, Elliott P, Katz PP, Smith JF. Time costs of fertility care: the hidden hardship of building a family. Fertil Steril. 2013;99(7):2025-2030. doi:10.1016/j.fertnstert.2013.01.145
10. Tan TY, Lau SK, Loh SF, Tan HH. Female ageing and reproductive outcome in assisted reproduction cycles. Singapore Med J. 2014;55(6):305-309. doi:10.11622/smedj.2014081
11. Nik Hazlina NH, Norhayati MN, Shaiful Bahari I, Nik Muhammad Arif NA. Worldwide prevalence, risk factors and psychological impact of infertility among women: a systematic review and meta-analysis. BMJ Open. 2022;12(3):e057132. Published 2022 Mar 30. doi:10.1136/bmjopen-2021-057132
12. Council for Disability Income Awareness. Disability Statistics. March 2025. Accessed June 6, 2025. https://thecdia.org/disability-statistics/