Fertility and Pregnancy: How Do These Affect Family Planning and Surgeon Health?

Abstract

There are unique considerations to fertility and pregnancy for women surgeons. Women surgeons often decide to delay pregnancy and childbearing due to concerns of conflict with work and training. This is particularly true for surgical trainees who face many obstacles, including bias from peers and program directors, and work–life conflict. As such, rates of infertility are higher compared with the general population. Women surgeons require assisted reproductive technologies more often than the general population. During pregnancy, there are also additional occupational hazards that are unique to a surgical career. Overall, we must be aware of these issues to support surgeons who decide to become parents during a surgical career.

There are more women in medicine and surgery than ever before, with an even greater proportion of women than men entering medical school. To retain the best candidates in the inspiring and technically demanding field of surgery, effort must be made to consider how surgical training and practice impacts family planning and pregnancy. While not all women surgeons desire children, many do. Therefore, it is necessary to consider how the field of surgery can best support female trainees and surgeons during their training and careers, as training is long, and fertility decreases as women age.

The median age for educated women to have their first child is higher than those who do not have advanced degrees. ¹ Women surgeons tend to delay childbearing for multiple reasons; this often results in challenges with fertility, pregnancy, the need for assisted reproductive technology (ART), and increased risks during pregnancy. The majority of the data we have on this topic are a result of survey data, which have inherent bias. ²

For these reasons, and to best support our surgeons and trainees, we must thoughtfully consider challenges women surgeons who want to have children face and how we can best support them.

Challenges to Fertility and Family Planning/Rates of Infertility

While all women physicians experience delayed childbearing and potential struggles with fertility, women surgeons experience this to an even greater degree. ³ For multiple reasons, women surgeons tend to be older at first birth compared with women in nonprocedural specialties. ⁴ Compared with the general population, women surgeons had their first child approximately 7 years later (30–34 vs 25 years) and fewer children overall (0.6–2.1 vs 2.7). ^{2 3 5} These trends also persist when comparing women surgeons to women nonsurgeons married to surgeons and therefore women with similar sociodemographics, with an average age of first birth of 33 versus 31 years. ⁶ Women surgeons have fewer biologic children than nonsurgeons and are more likely to delay having children until training was complete. ⁶ Women surgeons are more likely to be single or divorced compared with and less likely to be parents than their male counterparts. ⁷

Fertility declines with age, and by age 39, only 7% of women who want a pregnancy will be able to do so without intervention. ⁸ Surveys tell us that 48 to 98% of female residents delay childbearing because of work, the desire to avoid disrupting training, fear of obstetric complications, or concerns of negatively impacting their career. ^{1 2 9 10} With the typical timeline of surgical training, a woman would be at least 31 years old when completing surgical residency provided no additional time is taken for training or research.

Survey data reveal that only 25% of women choose to have their first child during the surgical residency, which is half as many as their male colleagues. ^{2 6 7} However, more than half of women surveyed would have liked to have a child. ¹¹ This suggests circumstances unique to women surgeons regarding pregnancy and childbearing that male surgeons may not encounter. Women residents are afraid to have children because of workload including unpredictable hours and call, stigma, concern for pregnancy health for self and baby, and abbreviated postpartum recovery. ^{5 9} Conversely male residents do not seem to receive the same negative perceptions that female residents face, and some even felt that they were regarded more highly after having children. ²

As women surgeons may decide to delay childbearing during training, infertility is a concern. Infertility rates were significantly higher among women surgeons than the general population (20–32 vs 11%). ^{2 4} The majority of infertility can be explained by delays in childbearing and increasing age; however, approximately 33% is not well understood. ^{2 5} While advanced age has clear limitations, women surgeons, even residents, can struggle with infertility for reasons that are not clear. Some may be due to excessive stress from work demands leading to physiologic or hormonal changes. ² Additionally, women surgeons are more than twice as likely than the general population to experience pregnancy loss. ⁶

Assisted Reproductive Technology

Due to delayed childbearing and increased age, women surgeons may be faced with consideration of ART use. The use of ART is four to six times higher among women surgeons compared with the general population. ^{2 4} Women surgeons are more likely to require the use of ART to have a successful pregnancy compared with male surgeons. Compared with male surgeons, female surgeons were less likely to have all the children they wanted without the use of ART, adoption, or surrogacy (35.3 vs 57.1%). ⁵ After controlling for surgeon gender, weekly hours worked, race, and insurance, only age > 35 years was associated with increased risk of needing ART. ⁵ Two-thirds of women surgeons who underwent ART took fewer than 3 days off to complete ART cycles with nearly 35% taking zero days off. ⁵

The cost of ART may even be prohibitive for some surgeons seeking to expand their families. A single cycle costs about $12,000 to $20,000. Most individuals will need to do three to six cycles to achieve a successful pregnancy. ⁵ About one-third of surgeons undergoing ART will pay more than $40,000 for ART. Despite differences in out-of-pocket costs, having state-mandated insurance coverage was not associated with increased use of ART. This finding also applied to trainees. ⁵

Pregnancy Complications

Women surgeons are more likely to have obstetric complications compared with nonsurgeons in the general population even after controlling for age, work hours, use of ART, and multiple gestation. ⁶ Complications occurred more significantly in women surgeons with age over 35 and operating more than 12 hours per week in the last trimester. ⁶ In this study, when compared with women nonsurgeons, women surgeons were over two times more likely to have preeclampsia, twice as likely to have pregnancy-related musculoskeletal disorders, over 1.5 times more likely to have nonelective cesarean delivery, and twice as likely to have postpartum depression. ⁶ Forty-two percent of women surgeons reported at least one pregnancy loss, which is higher compared with the general population. ⁶ Another study demonstrated that the largest risk of preterm delivery was working more than 40 hours per week compared with women working less than 40 hours. ¹² Similar findings were found in women orthopaedic surgeons who had an increased risk of preterm labor and early delivery, especially for those who worked more than 60 hours per week. ¹³

Given the rigors of surgical training, women trainees face similar increased risk of pregnancy-related complications. Todd et al found that residents had a five times greater risk of significant overall obstetric complications compared with the general U.S. population. ² Risk factors for obstetric complications were working more than 6 overnight calls per month or more than 60 hours per week. These complications included: higher rates of preterm labor (10.5 vs 5.9%), intrauterine growth restriction (10.5 vs 3.9%), involuntary miscarriage (13.3 vs 4.2%), and placental abruption (5.2 vs 0%). These risks are consistent with Finch's paper published in 2003. Despite more women in surgical disciplines, trainees continue to be at increased risk of pregnancy-related complications. ^{2 9}

Hazards

Women surgeons face several occupational hazards during the fertility or pregnancy journey. It is necessary to understand these factors to best protect pregnant surgeons and not necessarily limit their ability to operate or function in a clinical work situation. ¹⁴ These specifically include physical demands of work, radiation exposures, sharp injuries and blood-borne pathogens, surgical smoke, and toxic compounds.

Physical Demands of Work/Working Conditions

Surgical practice includes long working hours, prolonged standing, overnight call, and high physical workload. While there are variations in clinical practice and attending women surgeons who may have more control around their work schedules compared with trainees, there will always be more standing and moving in the average surgeon's daily life compared with most other occupations. These types of activities have all been thought to be associated with pregnancy complications, especially when working more than 40 hours per week compared with those working less than 40 hours per week. ¹⁴ Women surgeons are also over 5.5 times more likely to work more than 60 hours per week during pregnancy than nonsurgeons. ⁶ While only 16.5% of women surgeons decreased work schedules during pregnancy, 56.6% worked more than 60 hours per week and took more than 6 overnight calls per month during pregnancy. ⁶

Due to the physical demands of a surgical career, one could infer the importance of good ergonomics for pregnant surgeons. When musculoskeletal injury related to operating occurs in women orthopaedic reconstructive surgeons during pregnancy, it increasingly requires time off work or job modification. ¹⁵ Women surgeons versus nonsurgeons were more likely to have musculoskeletal disorders likely due to the physical nature of operations (25.5 vs 18.4%). ⁶ This shows a clear difference based on the usual expected activity of a surgeon, which includes prolonged standing and walking. This supports the idea of limiting overnight shifts and work hours for pregnant surgeons, or providing other support, to help prevent these problems and pregnancy-related complications.

Because the typical work schedule of women surgeons seems to be associated with obstetric complications, it is important to critically review the fact that most pregnant surgeons do not limit their work schedule. It is necessary for surgeons as a group to identify how to support pregnant colleagues' health and well-being.

Radiation

Women surgeons have the potential for radiation exposure, particularly in orthopaedics, neurosurgery, urology, and vascular surgery. This can be an even bigger concern with the increasing use of hybrid operating rooms (ORs) and angiography suites with more and more vascular interventions requiring angiographic intervention. Additional radiation exposure in pregnancy can be associated with increased risks of fetal death, intrauterine growth restriction, congenital anomalies, cognitive effects, and risk of childhood cancer. ¹⁶

The average normal annual exposure for any U.S. person is 6.2 mSv according to the U.S. Environmental Protection Agency. This includes background radiation from normal living and exposure to medical tests, industrial chemicals, minerals, etc. Currently, the consensus is that an exposure dose of less than 50 mGy or 50 mSv is safe in pregnancy. Exposure leading to fetal death is most sensitive during 0 to 2 weeks of gestation. Congenital anomalies can occur with doses up to 200 mSv during 2 to 8 weeks of gestation, with increasing and later exposure causing cognitive defects and microcephaly. Future risk of carcinogenesis is hard to quantify. ¹⁴ For this reason, many women wear two lead aprons during pregnancy. ¹⁷ The question is how much cumulative radiation are surgeons exposed to? Over 7 years, neurosurgery residents had an average radiation exposure of 1.73 mSv per year. ¹⁸ Vascular surgeons and urologists were monitored during pregnancy and had exposure doses of 0.27 to 7.31 mSv with fetal dosimeter, worn under the lead, at an average of 0. ¹⁷ Another large study looked at sentinel lymph node biopsy, reviewing 11 studies and 344 procedures. All exposures were within guidelines of 1 mSv if fewer than 100 procedures were performed during pregnancy. New instruments for measurements are more sensitive, and the exposure dose has decreased. Overall, these procedures may be considered safe, with no additional precautions needed. ¹⁹

Once pregnancy is identified, radiation exposure should be minimized. There are multiple guidelines that have been put forth by different organizations to help protect women in these fields. The National Council on Radiation Protection and Measurements recommends less than 0.5 mSv per month, and the U.S. Environmental Protection Agency recommends a limit of 5 mSV for the entire pregnancy. The International Commission on Radiological Protection recommends less than 1 mSv for the entire pregnancy. ²⁰

Blood-Borne Pathogens

Surgeons have a high risk of needle sticks and potential exposures due to the type of daily work performed. ^{21 22} As a group, surgeons have one of the highest risks in health care for needle sticks and exposures. Blood-borne pathogens of most concern would be HIV, hepatitis B, and hepatitis C. ^{14 21} Needle sticks or breaches in gloves may occur in 7 to 15% of operations, and the risk increases with longer and more invasive operations, with surgeons at the highest risk of all OR staff. ²³ The suture needle is the most common cause of injury. ²³ Seroconversion rates vary depending on many factors including patient and needle characteristics.

Glove failure is responsible for 61% of surgeon exposures. Double gloving would decrease risk of exposure to a patient's blood by 87%, making this an effective means of reducing risk. ²² While needle sticks and sharp exposure are inherent to work as a surgeon, there are ways to minimize this risk such as using blunt instruments when possible, neutral hands-free transfer zones for sharps, and double gloving. ^{21 23}

If injury occurs during pregnancy, it is important to consider postexposure prophylaxis and consult with employee health and obstetrics. Only postexposure prophylaxis exists for hepatitis B and HIV, and pre-exposure vaccination is most important to preventing hepatitis B transmission. There is currently no postexposure prophylaxis available for hepatitis C. Fortunately, there is a low seroconversion rate and low vertical transmission. Treatment with interferon for hepatitis C during pregnancy is contraindicated. ²⁴ Pregnant surgeons should be offered postexposure prophylaxis for hepatitis B if they are not vaccinated and for HIV. If an unvaccinated pregnant surgeon is exposed to hepatitis B, postexposure vaccination and immune globulin would reduce transmission rates significantly and is documented as safe. ^{23 25} Postexposure treatment for HIV exposure is safe for pregnant surgeons as well and should be offered immediately. ^{23 26} This is important because risk of transmission to the fetus is highest during acute infection; therefore, prophylaxis is vital to consider.

Surgical Smoke

Surgical smoke is the product created by electrosurgical devices in the OR, such as Bovie electrocautery, and can contain water, gas, particulate matter, cells, bacteria, and viruses. What is in the smoke depends on the tissue and device being used; the liver has the most particulate matter and fat has the lowest. ²⁷ There is a lack of evidence-based evaluation of the long-term effects of exposure. Most recommendations are based on smoke that the general population encounters. There can be components in the smoke that are carcinogenic despite a poor understanding of the composition. ²⁸

Surgical smoke does not appear to cause any immediate health hazard to most people, but long-term exposure to the particles may have synergistic and additive effects. The main carcinogenic components are benzene and 1,2-dichloroethane; however, it is unclear if people exposed to surgical smoke have higher rates of lung cancer. ²⁸

The best way for surgeons to protect themselves in the OR for potential dangers of surgical smoke is multifactorial. Surgical masks are good and necessary but cannot prevent particles less than 5 μm from passing. N95 masks are an option but are very uncomfortable. The Occupational Safety and Health Administration (OSHA) and National Institute for Occupational Safety and Health (NIOSH) have recommendations to minimize exposure, such as using smoke evacuators as compared with suction in the room and to adequately train staff; however, only 14% of people use smoke evacuators. ¹⁴ While OR ventilation is a consideration, surgeons often do not use smoke evacuators correctly or most effectively. ²⁸ Mechanical filters are good but electric filters may be even better. ²⁸

Intraoperative Compounds/Anesthetic Agents

In the OR, there are sources of chemical compounds that pregnant surgeons could encounter that are potentially dangerous. This includes inhaled anesthetic gases and medications used during specific operations. Inhaled anesthetic gases consist of two types: nitrous oxide and halogenated agents. Gas that leaks out of the closed-circuit anesthetic circuit into the surrounding room are identified as potential occupational reproductive hazards. There are guidelines that vary from organization and country regarding exposure limits because there are not well-established guidelines.

Original studies suggest that exposure to anesthetic gases resulted in an increased risk of spontaneous abortion with an overall risk of 1.9; however, more recent literature review concludes that there is too much heterogeneity in the data to draw this conclusion. ^{29 30} To minimize these risks, it is important for ORs to have adequate ventilation and exhaust systems in place, which is routine in the United States.

Two main compounds that pregnant surgeons may have exposure to are intraoperative chemotherapy and methyl methacrylate. Chemotherapies used in hyperthermic intraperitoneal chemotherapy (HIPEC) are generally mitomycin C and platinum, and exposure can be from skin contact or inhalation. There are guidelines for pregnant women involved with these operations to avoid handling these medications given the high degree of potential exposure. ¹⁴

Unique Considerations for Surgical Trainees

Surgical residents have unique considerations with respect to fertility and pregnancy. They may struggle with concerns about training and career, perceptions from colleagues, and higher rates of pregnancy complications. This may be partly due to increased physical demands of work in terms of physical activity and hours worked, and stress from training. In a survey by Rangel et al, most female residents have their pregnancy during their PGY3 year (83%), and only 22.3% had a pregnancy during clinical years compared with research years. ³¹ As discussed previously, obstetric complications among surgical residents are higher than average and may be higher than complications in attending surgeons. ² Miscarriage rates for residents range from 11 to 28%; however, it is difficult to determine if this rate includes terminations. ²

Pregnant surgical residents deal with significant physical and psychological stress related to pregnancy. Despite increasing numbers of women in surgery, there are persistent negative attitudes and perceptions against pregnant surgical residents. ^{2 9} Rangel et al found that 63.6% of pregnant residents were concerned about their work schedule harming their unborn baby's health, but were still afraid to ask for accommodations. ³¹ Over 85% of pregnant residents work an unmodified schedule and are afraid of negative perceptions from peers and faculty if they ask for accommodations during pregnancy. Less than 12% of programs reduced duty hours for pregnant residents and 95% of trainees continued overnight calls. ² Female residents tend to feel discrimination and guilt with pregnancy, mostly due to burdening their peers. This may result in a negative bias against pregnant residents in general. ^{2 9} Pregnant residents note mixed perceptions by resident peers. Some felt the work burden would increase and others felt empathetic and did not notice increased burden or work. ²

Men and women are perceived differently when having children during surgical residencies. Sixty-one percent of women residents were afraid of being perceived unfavorably if they had a child compared with 16% of men. ² Female residents felt more overwhelmed and less supported after a pregnancy, whereas male residents felt more supported after having a child. ^{2 32 33} There has not been a difference in attrition noted between male and female residents (18 vs 19%) or caseload between pregnant women versus nonpregnant women. ³⁴ Thirty percent of residents had a 10 to 20% decrease in American Board of Surgery Intraining Examination (ABSITE) scores after pregnancy without any eventual difference in board pass rates. ³⁵ Subjectively, there is mixed literature between how women residents felt in relation to their work. In one study, 74% of residents did not perceive that pregnancy had a negative effect on training; however, another study reported that 50% of residents felt their knowledge and technical skills were not where they had been. ^{2 35 36}

Surgical resident program directors (PDs) can provide support and guidance; however, on review of the literature, there are mixed findings. Sandler et al performed a survey of general surgery PDs and found that most PDs supported a flexible track residency for pregnant residents; however, there is still negative perception toward pregnant trainees. ³³ When asked when the best time to have a child might be, 46% of university PDs said the laboratory years were the best, and 52% of independent programs said no time was better than another. Fifteen percent of PDs said they would advise against a pregnancy during residency. This could be a problem of subtly discouraging residents from having children and representing a negative culture. ³³ PDs were less likely to report that becoming a parent affected male trainee's work, but did for women (34 vs 61%). They also perceived having a child decreased a woman resident's well-being. ³³

Having a child during training will affect both an individual's personal and professional life and goals. Fifteen percent of women trainees changed fellowship or career plans based on work–life balance, and 39% of respondents said pregnancy made them strongly reconsider surgical training. ^{2 31} Thirty-nine to 84% of women pursued research or graduate degrees while on maternity leave. ² Interestingly, 29.5% of surgical residents who had a pregnancy during training would caution women medical students against surgery, and 30% actually discouraged medical students from going into surgery related to their personal experiences with pregnancy and motherhood. ^{2 31} Two-thirds of female surgical residents wished they had a mentor to help them deal with issues around childbearing and provide supportive resources. ^{2 31} This may underscore the importance of a mentor or colleagues to support women surgeons in balancing these two roles and even find ways to thrive, thereby supporting the next generation of women surgeons who come after them.

Other Considerations

In addition to traditional ways of becoming a parent, other alternatives should be discussed to promote inclusiveness to all surgeons and family situations.

When ART is not chosen or unsuccessful, families can be created using adoption or surrogacy. Adoption and surrogacy are less well understood for surgeons because they are often used by couples who have failed fertility treatment or by same-sex couples. Individuals who use these means to have a child may be at increased risk of workplace discrimination. In a survey by Atkinson et al, of the 27 surgeons who became parents through adoption or surrogacy, 5 (18.5%) were in same-sex relationships. Eight surgeons used surrogacy and 75% spent more than $40,000 in out-of-pocket expenses. Thirteen women surgeons used adoption and 52% spent more than $40,000. Of this group, 31% of surgeons took no parental leave after adoption and 50% took no parental leave after surrogacy. ⁵

Alternatively, both partners should be considered when formal policies are created for fertility support or childbearing. This includes women at all stages of their career, from training to active practice. When in practice, women surgeons may have more control over their time spent in clinical activities; however, this is not always the case, especially for employed surgeons. Having a formal policy would support women and their partners who choose to grow a family so they know they will be accommodated and can plan accordingly. Sandler et al survey of general surgery PDs found that most programs allotted 6 weeks of maternity leave and 1 to 2 weeks for the nonchildbearing partners. ³³ However, policies are not always inclusive to the nonchildbearing partner or to adoption or surrogacy. Terminology should be inclusive when defining these policies. Both parents are involved in child raising and using terminology such as parental leave is more inclusive. ³³

Conclusion

Women surgeons continue to have unique considerations surrounding family planning that are not equivalent to their male partners. Women surgeons often delay childbearing due to work obligations, and this results in increased rates of infertility and obstetric complications. Pregnant surgeons also face multiple hazards during normal clinical practice that are unique to this occupation, leaving them vulnerable to increased obstetric complications compared with the general population. These struggles are even more true for surgical trainees who encounter significant biases against them from leadership and peers, even when it is not explicit. As the next generation of surgical leaders, a more inclusive environment for pregnant surgeons and for those who wish to grow their family in whatever capacity must be created. Women can be both surgeons and mothers if desired. Implementation strategies include mentorship for younger surgeons considering when and how to start their family, and for those in leadership roles, to create a safer environment for trainees and colleagues who are growing their families by setting policies to create a supportive culture.