Abstract
Background
Deciding when to pursue parenthood can be difficult for medical trainees and infertility is more common in the physician population. However, few studies have examined the views of very early career trainees. The goal of this study was to assess premedical and medical student plans for family building, knowledge of fertility, and thoughts on assisted reproductive technology, as well as institutional support for parenthood in medical school and fertility curriculum.
Methods
Web-based cross-sectional survey on Qualtrics distributed through social media and school organization-based networks. Responses were reported as frequency and percent and compared across subgroups of population with χ2 tests.
Results
The study had a total of 605 premedical and medical students respondents. Most students (78%) do not have children but plan to have children in the future. Almost two-thirds (63%) of students would consider using assisted reproductive technology. More than 80% of respondents have considered or would consider oocyte cryopreservation for themselves or their partners. A majority (95%) of students are worried about balancing parenthood and a career in medicine and about their fertility declining while they complete medical training (84%). The most frequently cited barriers to family planning during medical school and residency were: limited time off during training (84%), demands of training (82%), cost of having a child (59%), and stigma of having a child during training (45%). Less than half of medical students had formal education on infertility.
Conclusions
Premedical and medical students are worried about fertility declining in training and about balancing parenthood and medical careers, but gaps in knowledge and institutional support exist.
Introduction
Medical trainees face challenges with family building and fertility, including issues related to parental leave, childcare, and lactation support. 1 There is a growing emphasis on addressing these barriers in graduate medical education. 1–7 However, less attention has been paid to premedical and medical students, who may have similar experiences as later-career physicians.
Many physicians choose to delay childbearing and frequently cite their career or education as the primary reason. 8–11 Trainees who do delay may encounter issues of declining fertility with increasing age. 12–17 The rate of infertility in physicians is estimated to be twice that of the general population, and one-third of infertility cases in this population have been attributed to age or diminished ovarian reserve. 9 Initiating childbearing at a later age may also increase the likelihood of adverse reproductive outcomes. 12,18 LGBTQ+ physicians also face a disproportionate burden of family planning challenges—including increased costs of assisted reproductive technology (ART), adoption, and surrogacy. Medical institutions are also less likely to have supportive policies for these options. 19
Despite the prevalence of infertility, there are gaps in knowledge on age-related fertility decline and the success of ART in both the general and physician populations. 20–27 Studies of university students, 28 students in graduate school programs, 29,30 and medical students, 27,31,32 who may delay childbearing for career or educational pursuits, have also shown similar results.
It is valuable to better understand the family planning intentions and baseline fertility knowledge of the student population. This knowledge may be used to develop earlier educational programming and policies to support future trainees. This paper sought to investigate the family building intentions of premedical and medical students, barriers to building a family during medical training, and knowledge and perceptions of fertility and ART in premedical and medical students.
Methods
Current premedical and medical students (N = 605) who intend to practice in the United States after medical school were recruited to participate in an anonymous, voluntary, 10-minute questionnaire through Qualtrics, a commonly utilized, secure survey platform. Study information was disseminated widely, including sharing to all American Medical Women’s Association social media platforms and branch listservs, the American Medical Association Students Facebook group, and various medical institution student groups. The study was approved by the institutional review board at the University of Southern California.
No compensation was provided for study participation. Data were collected over a 5-week period from October to December 2021, with recruitment blasts sent on the first day, midpoint, and 1 week before survey closure.
Survey
The 30-question survey was developed based on extensive literature review of similar survey questions. Most questions are taken from the FIT-KS survey, which has been used in the medical student population. 27 Other surveys were reviewed and concepts were incorporated as appropriate. 16,23,33–35 Question choice was guided by the clinical experience of investigators and existing studies.
Survey respondents were asked to describe their plans for parenthood. Those who responded that they intended to have children were asked further questions regarding number, timing, perceived barriers, and support. A section of this survey focused on ART. Respondents were first asked questions relating to their experience with infertility and ART, as well as their thoughts on future family planning as it relates to these topics. A series of knowledge questions followed, aiming to ascertain respondent understanding of basic reproductive physiology and ART.
At the end of the survey, respondents were given the opportunity to write a free-text response about their plans to build a family throughout medical training. These answers provided further insight and context to the quantitative data collected.
Statistical analysis
Descriptive statistics were used to describe population characteristic and survey responses. Continuous variables were reported as mean (standard deviation) and compared with one-way ANOVA test across subgroups for population (premedical students, medical students, others). Categorical variables were reported as frequency (percent) and compared across subgroups with χ2 test. The analysis was conducted using STATA version 16 (StataCorp) and a p value of 0.05 was considered significant.
Results
Demographics
Demographics are reported in Table 1. The average age of all respondents was 25.2 ± 3.7 years. Most participants self-identified as female (90.4%). Among participants, 511 identified as women (88.9%), 53 as men (9.2%), 6 as nonbinary (1.0%), and 5 as transgender (0.9%). Most self-identified as heterosexual (450, 77.7%), while 63 self-identified as bisexual (10.9%), 9 as gay (1.6%), 16 as lesbian (2.8%), 17 as queer (2.9%), and 24 as other identities including pansexual, questioning, demisexual, asexual, and prefer not to answer (4.0%). Most respondents were medical students or recent medical school graduates within the last 6 months (n = 401, 66%). Of the remaining participants, 177 were premedical students (29%) and 26 (4%) were “other” (19 currently pursuing a concurrent degree—MBA, PhD, etc, 7 taking time off for another reason, and 1 unknown). The majority of participants were partnered (71.5%), but premedical students were less likely to be partnered than medical students (58.9% vs 76.2%) or those pursuing concurrent degrees/taking time off (75.0%).
Table 1:
Demographics of study population among total survey responders and comparison by current educational status
| Characteristic | Overall n(%) a | Premedical students; n(%) a | Medical students; n(%) a | Other; n(%) a b | p value e |
|---|---|---|---|---|---|
| Age, y (± SD) | 25.3 ± 3.6 | 23.9 ± 4.8 | 25.9 ± 2.8 | 26.3 ± 3.4 | < 0.001 |
| Gender identity | 0.02 | ||||
| Woman | 511 (88.9) | 154 (91.7) | 334 (88.1) | 23 (82.1) | |
| Man | 53 (9.2) | 11 (6.6) | 40 (10.6) | 2 (7.1) | |
| Nonbinary | 6 (1.0) | 2 (1.2) | 3 (0.8) | 1 (3.6) | |
| Transgender woman | 2 (0.4) | 0 | 1 (0.3) | 1 (3.6) | |
| Transgender man | 3 (0.5) | 1 (0.6) | 1 (0.3) | 1 (3.6) | |
| Prefer not to answer | 0 (0) | 0 (0) | 0 (0) | 0 (0) | |
| Prefer to describe | 0 (0) | 0 (0) | 0 (0) | 0 (0) | |
| Sex assigned at birth | 0.30 | ||||
| Male | 55 (9.6) | 11 (6.6) | 41 (10.8) | 3 (10.7) | |
| Female | 521 (90.4) | 156 (93.4) | 340 (89.2) | 25 (89.3) | |
| Intersex | 0 (0) | 0 (0) | 0 (0) | 0 (0) | |
| Prefer not to answer | 0 (0) | 0 (0) | 0 (0) | 0 (0) | |
| Prefer to describe | 0 (0) | 0 (0) | 0 (0) | 0 (0) | |
| Sexual orientation | 0.40 | ||||
| Heterosexual | 450 (77.7) | 124 (73.4) | 308 (80.6) | 18 (64.29) | |
| Gay | 9 (1.6) | 3 (1.8) | 5 (1.3) | 1 (3.6) | |
| Bisexual | 63 (10.9) | 23 (13.6) | 37 (9.7) | 3 (10.7) | |
| Demisexual | 4 (0.7) | 1 (0.6) | 2 (0.5) | 1 (3.6) | |
| Fluid | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | |
| Asexual | 2 (0.3) | 0 (0.0) | 2 (0.5) | 0 (0.0) | |
| Lesbian | 16 (2.8) | 5 (3.0) | 9 (2.4) | 2 (7.1) | |
| Pansexual | 9 (1.5) | 5 (3.0) | 3 (0.8) | 1 (3.5) | |
| Queer | 17 (2.9) | 5 (3.0) | 10 (2.6) | 2 (7.1) | |
| Questioning | 7 (1.2) | 3 (1.8) | 4 (1.0) | 0 (0.0) | |
| Prefer not to answer | 2 (0.3) | 0 (0.0) | 2 (0.5) | 0 (0.0) | |
| Prefer to describe | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | |
| Race d | < 0.001 | ||||
| White | 391 (67.5) | 100 (59.2) | 275 (72.0) | 16 (57.1) | |
| Hispanic, Latinx, or Spanish origin | 78 (13.5) | (11.8) | (6.5) | (14.3) | |
| Black or African American | 38 (6.6) | 14 (8.3) | 19 (5.0) | 5 (17.9) | |
| Multi-Race | 27 (4.7) | 8 (4.1) | 17 (4.4) | 3 (10.7) | |
| American Indian or Alaskan Native | 6 (1.0) | 2 (1.2) | 4 (1.1) | 0 (0) | |
| Asian | 104 (18.0) | 31 (18.3) | 66 (17.3) | 7 (25.0) | |
| Middle Eastern | 20 (3.5) | 7 (4.1) | 12 (3.1) | 1 (3.6) | |
| Native Hawaiian or Pacific Islander | 0 (0) | 0 (0) | 0 (0) | 0 (0) | |
| Prefer to describe | 5 (0.9) | 0 (0) | 5 (1.3) | 0 (0) | |
| Prefer not to answer | 0 (0) | 0 (0) | 0 (0) | 0 (0) | |
| Relationship status | 0.02 | ||||
| Partnered total | 414 (71.5) | 101 (59.8) | 291 (76.2) | 22 (78.6) | |
| Married | 102 (17.6) | 26 (15.4) | 69 (18.1) | 7 (25.0) | |
| Domestic partner | 17 (2.9) | 6 (3.6) | 10 (2.6) | 1 (3.6) | |
| In a relationship | 295 (51.0) | 69 (40.8) | 212 (55.5) | 14 (50.0) | |
| Not partnered total | 164 (28.4) | 68 (40.2) | 90 (23.6) | 6 (21.4) | |
| Single | 163 (28.2) | 68 (40.2) | 89 (23.3) | 6 (21.4) | |
| Widowed | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | |
| Divorced | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | |
| Separated | 1 (0.2) | 0 (0.0) | 1 (0.3) | 0 (0.0) | |
| Future specialty | |||||
| Surgical total | 135 (34.5) | ------ | ------ | ------ | |
| General surgery/surgery/ undifferentiated surgical subspecialty | 29 (7.4) | ------ | ------ | ------ | |
| Obstetrics & gynecology | 69 (17.6) | ------ | ------ | ------ | |
| Otolaryngology | 3 (0.8) | ------ | ------ | ------ | |
| Plastic surgery | 4 (1.0) | ------ | ------ | ------ | |
| Orthopedic surgery | 11 (2.8) | ------ | ------ | ------ | |
| Urology | 3 (0.8) | ------ | ------ | ------ | |
| Ophthalmology | 9 (2.3) | ------ | ------ | ------ | |
| Neurosurgery | 4 (1.0) | ------ | ------ | ------ | |
| Undecided surgery | 3 (0.8) | ------ | ------ | ------ | |
| Non-surgical total | 233 (59.6) | ------ | ------ | ------ | |
| Anesthesiology | 9 (2.3) | ------ | ------ | ------ | |
| Neurology | 5 (1.3) | ------ | ------ | ------ | |
| Child neurology | 1 (0.2) | ------ | ------ | ------ | |
| Child psychiatry | 1 (0.2) | ------ | ------ | ------ | |
| Psychiatry | 13 (3.3) | ------ | ------ | ------ | |
| Family medicine/ community medicine |
46 (11.8) | ------ | ------ | ------ | |
| Dermatology | 15 (3.8) | ------ | ------ | ------ | |
| Emergency medicine | 32 (8.2) | ------ | ------ | ------ | |
| Emergency-internal medicine combined |
1 (0.2) | ------ | ------ | ------ | |
| Internal medicine | 40 (10.2) | ------ | ------ | ------ | |
| Medicine-pediatrics | 7 (1.8) | ------ | ------ | ------ | |
| Pathology | 4 (1.0) | ------ | ------ | ------ | |
| Pediatrics | 39 (9.9) | ------ | ------ | ------ | |
| Primary care | 3 (0.8) | ------ | ------ | ------ | |
| Radiology | 7 (1.8) | ------ | ------ | ------ | |
| Physical medicine & rehabilitation | 6 (1.5) | ------ | ------ | ------ | |
| Undecided non-surgery | 4 (1.0) | ------ | ------ | ------ | |
| Undecided | 23 (5.9) | ------ | ------ | ------ |
Total numbers may vary due to item non-response or missing
Other: currently pursuing another concurrent degree (ie, MPH, PHD, MBA etc) or currently taking time off for other reasons
All statistical tests were χ2 with the exception of age which was a one-way ANOVA
Totals equal more than 100% because participants were allowed to select more than one answer
p values < 0.05 were considered significant and represent comparisons across subgroups of students
Student thoughts and future plans
Findings related to students’ thoughts on family building, ART, and fertility preservation are shown in Table 2. Most students (77.8%) do not have children but plan to have children in the future, with most planning to have children during residency or fellowship (76.5%), or after training is complete (40.4%). Very few participants (3.3%) reported that they or their partners had experienced infertility, but almost two-thirds (63.6%) would consider using ART to have children. More than 85% of respondents have considered or would consider oocyte cryopreservation for themselves or their partners. Premedical students and medical students did not differ significantly in the number of children they want to have, and most students wanted between 1 and 3 children (88.4%).
Table 2:
Future fertility plans and knowledge among total survey responders and comparison by current educational status
| Characteristic | Total n(%) a | Premedical students; n(%) a | Medical students; n(%) a | Other; n(%) a , b | p value f |
|---|---|---|---|---|---|
| Which of the following best describes your plan for parenthood? | 0.001 | ||||
| Already have children and plan to have more | 24 (4.2) | 3 (1.8) | 16 (4.2) | 5 (17.9) | |
| Already have children and do not plan to have more | 9 (1.6) | 6 (3.6) | 3 (0.8) | 0 (0.0) | |
| Do not have children and plan to have children | 450 (77.8) | 123 (73.2) | 309 (81.1) | 18 (64.3) | |
| Do not have children and do not plan to have children | 46 (8.0) | 19 (11.3) | 24 (6.3) | 3 (10.7) | |
| I do not know | 48 (8.3) | 17 (10.1) | 29 (7.6) | 2 (7.1) | |
| At what point in your training do you plan to have children? c | |||||
| During medical school | 91 (15.7) | 39 (23.1) | 45 (11.8) | 7 (25.0) | 0.001 |
| During residency | 263 (45.4) | 68 (40.2) | 184 (48.2) | 11 (39.3) | 0.18 |
| During fellowship | 180 (31.1) | 58 (34.3) | 116 (30.4) | 6 (21.4) | 0.34 |
| After training is complete | 234 (40.4) | 63 (37.3) | 164 (42.9) | 164 (42.9) | 0.11 |
| I do not know | 234 (40.4) | 63 (37.3) | 164 (42.9) | 164 (42.9) | 0.11 |
| How many children would you like to have? | 0.57 | ||||
| 1 | 25 (4.8) | 6 (4.2) | 17 (4.8) | 2 (8.0) | |
| 2 | 260 (50.0) | 76 (53.2) | 171 (48.6) | 13 (52.0) | |
| 3 | 175 (33.7) | 45 (31.5) | 121 (34.4) | 9 (36.0) | |
| 4 | 45 (8.7) | 8 (5.6) | 36 (10.2) | 1 (4.0) | |
| 5+ | 15 (2.9) | 8 (5.6) | 7 (2.0) | 0 (0.0) | |
| Have you or your partner ever experienced infertility? d | 0.001 | ||||
| Yes | 19 (3.3) | 7 (4.2) | 8 (2.1) | 4 (14.8) | |
| No | 551 (96.7) | 160 (95.8) | 368 (97.9) | 23 (85.2) | |
| Would you consider using ART to have children? | 0.43 | ||||
| Yes | 367 (63.6) | 102 (60.4) | 247 (65.0) | 18 (64.3) | |
| No | 71 (12.3) | 26 (15.4) | 40 (10.5) | 5 (17.9) | |
| Not sure | 139 (24.1) | 41 (24.3) | 93 (24.5) | 5 (17.9) | |
| Have you ever considered oocyte cryopreservation (egg freezing) for yourself or your partner? | 0.13 | ||||
| I have frozen eggs in the past | 3 (0.5) | 0 (0.0) | 2 (0.5) | 1 (3.6) | |
| I have considered egg freezing but have not pursued it | 184 (31.9) | 43 (25.4) | 132 (34.8) | 9 (32.1) | |
| I have considered egg freezing and tried to pursue it but experienced barriers | 16 (2.8) | 6 (3.6) | 9 (2.4) | 1 (3.6) | |
| I have not considered egg freezing, but I would consider it in the future | 298 (51.7) | 94 (55.6) | 192 (50.7) | 12 (42.9) | |
| I would never consider egg freezing | 76 (13.0) | 26 (15.4) | 44 (11.6) | 5 (17.9) | |
| During medical school have you had lectures on: | |||||
| Infertility | 188 (32.5) | ------ | ------ | ------ | |
| Age-related fertility decline | 193 (33.3) | ------ | ------ | ------ | |
| Egg freezing | 53 (9.2) | ------ | ------ | ------ | |
| In vitro fertilization | 108 (18.7) | ------ | ------ | ------ | |
| Over which age range does a female’s ability to get pregnant decline most precipitously? e (Answer: 35–39) | 0.15 | ||||
| Answered correctly | 353 (61.2) | 96 (56.8) | 236 (62.11) | 21 (75.0) | |
| Answered incorrectly | 224 (38.8) | 73 (43.2) | 144 (37.9) | 7 (25.0) | |
| What is the average cost of an IVF cycle in the USA? e (Answer: $12,000) | 0.24 | ||||
| Answered correctly | 122 (21.1) | 30 (17.8) | 88 (23.2) | 4 (14.3) | |
| Answered incorrectly | 455 (78.9) | 139 (82.3) | 292 (76.8) | 24 (85.7) | |
| A female’s eggs are as old as they are. e | 0.15 | ||||
| True (correct) | 451 (78.2) | 130 (76.9) | 295 (77.6) | 26 (92.9) | |
| False (incorrect) | 126 (21.8) | 39 (23.1) | 85 (22.4) | 2 (7.1) | |
| Male factors contribute to infertility much less often than female factors. e | 0.71 | ||||
| True (incorrect) | 159 (27.7) | 44 (26.0) | 109 (28.8) | 6 (21.4) | |
| False (correct) | 414 (72.0) | 125 (74.4) | 267 (70.6) | 22 (78.6) | |
Total numbers may vary due to item non-response or missing.
Other: currently pursuing another concurrent degree (ie, MPH, PhD, MBA etc) or currently taking time off for other reasons.
Participants were allowed to select more than 1 option.
Defined generally as failure to achieve pregnancy within 12 mo of unprotected intercourse.
Knowledge question from FIT-KS scale.
p values < 0.05 were considered significant and represent comparisons across subgroups of students.
ART, assisted reproductive technology; IVF, in vitro fertilization.
Knowledge and education
Medical student educational experiences and knowledge of fertility related topics are also shown in Table 2. Fertility and fertility preservation education was lacking in medical school curriculums, with less than half receiving lectures on age-related fertility decline (33.3%), infertility (32.5%), in vitro fertilization (18.7%), or oocyte cryopreservation (9.2%). Fertility knowledge did not differ significantly between stages of education. More than 75% of students incorrectly estimated the cost of in vitro fertilization treatment and only 61% correctly identified the period in which female fertility declines most precipitously. The majority of premedical and medical students selected the correct answer for questions regarding the age of a female’s eggs (78.2%) and the contribution of male (vs) female factors to infertility (72.0%).
Student fears and barriers
Student fears and perceived barriers to family building are presented in Table 3. Most participants (83.5%) agreed or strongly agreed that they are worried about their fertility declining while they complete their medical training and about balancing parenthood and a medical career (94.3%). Ninety-seven percent agreed or strongly agreed that a career in medicine impacts childbearing decisions, with 80.9% agreeing that they would have been more likely to have children earlier in life if they were not pursuing medicine. The most common perceived barriers to family building during medical school and residency were: limited time off during training (83.8%), demands of training (82.0%), cost of having a child (59.2%), stigma of having a child during training (44.9%), not partnered or waiting for right partner (22.5%), lack of family or social support (22.5%), other (7.4%), and none of the above (0.4%).
Table 3:
Barriers and fears associated with family building
| Characteristic | n(%) a |
|---|---|
| What barriers do you perceive to having children during medical school or residency training? b | |
| Cost of having a child | 343 (59.2) |
| Limited time off during training | 485 (83.8) |
| Demands of training | 475 (82.0) |
| Stigma of having a child during training | 260 (44.9) |
| Lack of family or social support | 130 (22.5) |
| Not partnered or waiting for right partner | 130 (22.5) |
| Other | 43 (7.4) |
| None of the above | 2 (0.4) |
| Which of the following are barriers to pursuing egg freezing for yourself or your partner? b | |
| Don’t know enough about the process | 274 (47.3) |
| Cost | 441 (76.2) |
| Time | 209 (36.1) |
| Don’t feel it is necessary | 140 (24.2) |
| Social stigma | 40 (6.9) |
| Cultural beliefs about ART | 27 (4.7) |
| Religious beliefs about ART | 43 (7.4) |
| Other | 55 (9.5) |
| None of the above | 18 (3.1) |
| Which of the following factors would increase the likelihood of pursuing egg freezing for yourself or your partner? b | |
| Insurance coverage | 466 (80.5) |
| If I decided to complete longer training | 274 (47.3) |
| If there were policies from my medical school or residency program supporting time off for appointments and treatments | 346 (59.8) |
| If I had more education about egg freezing | 291 (50.3) |
| If I knew someone else who had been through the process of egg freezing | 231 (39.9) |
| If my doctor talked with me about egg freezing | 255 (44.0) |
| Other | 12 (2.1) |
| None of the above | 63 (10.9) |
| Characteristic | Total n(%) a | Premedical student; n(%) a | Medical student; n(%) a | Other; n(%) a , c | p value d |
|---|---|---|---|---|---|
| I am worried about my fertility declining while I am in training. | 0.91 | ||||
| Strongly agree | 263 (50.4) | 74 (51.4) | 174 (49.3) | 15 (60) | |
| Somewhat agree | 173 (33.1) | 45 (31.3) | 120 (34.0) | 8 (32.0) | |
| Neutral | 24 (4.6) | 9 (6.3) | 14 (4.0) | 1 (4.0) | |
| Somewhat disagree | 24 (4.6) | 6 (4.2) | 18 (5.1) | 0 (0.0) | |
| Strongly disagree | 27 (5.2) | 8 (5.6) | 18 (5.1) | 1 (4.0) | |
| Not applicable | 11 (2.1) | 2 (1.4) | 9 (2.6) | 0 (0.0) | |
| If my partner or I were to become pregnant during my time in medical school, we would have good support from my school (for flexible time off, resources, etc). | < 0.001 | ||||
| Strongly agree | 20 (3.8) | 2 (1.4) | 18 (5.1) | 0 (0) | |
| Somewhat agree | 96 (18.4) | 16 (11.1) | 76 (21.5) | 4 (16.0) | |
| Neutral | 119 (22.8) | 21 (14.6) | 95 (26.9) | 3 (12.0) | |
| Somewhat disagree | 130 (24.9) | 32 (22.2) | 91 (25.8) | 7 (28.0) | |
| Strongly disagree | 84 (16.1) | 14 (9.7) | 62 (17.6) | 8 (32.0) | |
| Not applicable | 73 (14.0) | 59 (41.0) | 11 (3.1) | 3 (12.0) | |
| I feel that a career in medicine impacts childbearing decisions | 0.17 | ||||
| Strongly agree | 391 (74.9) | 95 (66.0) | 274 (77.6) | 22 (88.0) | |
| Somewhat agree | 115 (22.0) | 42 (29.2) | 70 (19.8) | 3 (12.0) | |
| Neutral | 4 (0.77) | 1 (0.7) | 3 (0.9) | 0 (0) | |
| Somewhat disagree | 7 (1.3) | 4 (2.8) | 3 (0.9) | 0 (0) | |
| Strongly disagree | 4 (0.8) | 1 (0.7) | 3 (0.9) | 0 (0) | |
| Not applicable | 1 (0.2) | 1 (0.7) | 0 (0) | 0 (0) | |
| If I chose a career other than medicine, I would have been more likely to have children earlier in life. | 0.12 | ||||
| Strongly agree | 220 (42.2) | 60 (41.7) | 145 (41.1) | 15 (60.0) | |
| Somewhat agree | 202 (38.7) | 46 (31.9) | 149 (42.2) | 7 (28.0) | |
| Neutral | 45 (8.6) | 15 (10.4) | 29 (7.9) | 2 (8.0) | |
| Somewhat disagree | 31 (5.9) | 11 (7.6) | 19 (5.4) | 1 (4.0) | |
| Strongly disagree | 23 (4.4) | 11 (7.6) | 12 (3.4) | 0 (0) | |
| Not applicable | 1 (0.2) | 1 (0.7) | 0 (0) | 0 (0) | |
| I am worried about balancing parenthood and my career in medicine in the future. | 0.30 | ||||
| Strongly agree | 366 (70.0) | 105 (72.9) | 242 (68.4) | 19 (76.0) | |
| Somewhat agree | 127 (24.3) | 29 (20.1) | 94 (26.6) | 4 (16) | |
| Neutral | 9 (1.7) | 3 (2.1) | 6 (1.7) | 0 (0) | |
| Somewhat disagree | 16 (3.1) | 4 (2.8) | 11 (3.1) | 1 (4.0) | |
| Strongly disagree | 5 (1.0) | 3 (2.1) | 1 (0.3) | 1 (4.0) | |
| Not applicable | 0 (0) | 0 (0) | 0 (0) | 0 (0) | |
Total numbers may vary due to item non-response or missing.
Participants were allowed to select more than 1 option.
Other: currently pursuing another concurrent degree (ie, MPH, PhD, MBA etc) or currently taking time off for other reasons.
p values < 0.05 were considered significant and represent comparisons across subgroups of students.
Similarly, there were a number of barriers students perceived to pursuing egg freezing for themselves or their partners. The most frequent barrier was cost (76.2%), followed by not knowing enough about the process (47.3%), and time (36.1%). Other barriers included not feeling it was necessary (24.2%), religious beliefs about ART (7.4%), social stigma (6.9%), and cultural beliefs about ART (4.7%). There were many factors that would increase the likelihood of pursuing egg freezing, including insurance coverage (80.5%), supportive policies from their school/program (59.8%), increased education on egg freezing (50.3%), whether they decided to pursue longer training (47.3%), whether their doctor talked with them about egg freezing (44.0%), or whether they knew someone else who had gone through the egg freezing process (39.9%).
Out of 522 who answered whether they felt their school would provide good support if they or their partner were to become pregnant, 214 disagreed or strongly disagreed (41.0%), 119 were neutral (22.8%), and only 116 agreed or strongly agreed (22.2%).
Free response
Table 4 shows a selection of free response answers from participants. A total of 203 participants answered the free response question. Many responses fit into the categories of age/timing, support, cost, stigma, and reproductive decision making.
Table 4:
Free response (optional): “Do you have any other thoughts you’d like to share with us about your plans to build a family?”
| Theme | Example quote |
|---|---|
| Age/Timing | “As a premedical student, I am planning to have children when my partner and I feel ready rather than trying to wait for the best time during or after training. This may be naive, but I am very worried about waiting too long and having age-related fertility issues.” |
| “I know due to my age I will need to have children during medical school and residency and I am very nervous that I will face limited opportunities or backlash due to this.” | |
| “I would probably choose to try to have children in 2 years if I wasn’t in medicine, instead I’m planning to wait until the end of residency in 4 years and hoping I don’t encounter difficulty when we start trying.” | |
| “As an LGBTQ+ person, I always thought that family planning would be pushed off until later in life when I had the stability, finances, support, etc to go about building my family. Being a LGBTQ+ in medicine has only pushed that process further back and has put more barriers in front of that process.” | |
| Support | “Family leave is not widely discussed and I do not know what policies are around to support me if I choose to become a parent. I do not know where I will be for residency and this has impacted my relationship as my recent partners have been opposed to long-distance relationships.” |
| “I think that it is difficult to think about having kids when the infrastructure is stacked against you. While some institutions are looking to change, there is not a large enough movement to enact large changes nationwide.” | |
| “If the system was more supportive I would be looking more into having a family earlier, but at this stage feel pressure to not conceive which makes me worry for my future. I worry that by the time I am out of my medical training I will have a short span to create a family which makes me stressed I won't conceive.” | |
| “I'm currently pregnant with my second child in my second year of medical school and have been faced with a lot of difficulty working with my school for accommodating me and presenting options.” | |
| Cost | “I think if residency programs were required to cover egg freezing in our insurance plans, that would alleviate a lot of my stress. I’m sure that most female physicians or soon-to-be physicians would agree.” |
| “I find it ironic that in a career about medicine there’s hardly any support for fertility treatments or cost support. It is incredibly disappointing and almost discriminatory to limit women that way.” | |
| “As a gay man, I have only 2 very expensive and time consuming options: adoption (vs) IVF & surrogacy. I’m not sure when I’ll be financially stable enough or have enough time to devote to having a child.” | |
| “Student loan debt payments are an extremely influential component in this decision, especially for those coming from backgrounds that required a high number of loans to afford education and training. Residents are not paid very highly and also have to repay loans, so if the partner finds it necessary to stay home and take care of a child, an income is lost which could greatly negatively impact the odds of planning to have another child.” | |
| Stigma | “I’ve had 2 children during medical school, and it has been very challenging. The worst part was having no postpartum leave and returning 1 week postpartum each time. The second worst part was dealing with judgment from attendings, residents, and peers and lack of support for breastfeeding.” |
| “I hoped to have a child third year but decided not to do so because of the stigma in residency and how I will be perceived during audition rotations fourth year if I'm pregnant. I wish it wasn't this hard.” | |
| Reproductive decision making | “I believe that my indecision about whether or not to have children at all is in large part impacted by my decision to pursue medicine. Had I gone into a field that was less demanding, I think I would want to have children.” |
| “The more I have decided to pursue medicine the more I feel inclined to put off kids or not have them at all.” |
IVF, in vitro fertilization.
Discussion
The results of this study overwhelmingly demonstrate that premedical and medical students are concerned about family building and fertility at the early stages of their medical training. Much of the current literature has focused on later-stage trainees and physicians, but this study demonstrates a need for institutional support and education at earlier stages. These data underscore the importance of comprehensive fertility and reproductive life planning support and education in medical training.
A majority of students would not feel supported by their institution if they became parents during school. And while most respondents intend to have children during residency or fellowship, a small but substantial minority have children already or plan to have children during medical school. These data are consistent with statistics released from the Association of American Medical Colleges that about 7% of graduating medical students are parents. 36 Students in this survey identified cost, limited time off, demands of training, and stigma as barriers to having children during medical school and residency. These results echo previous studies of resident physicians 1–7 and demonstrate a need for better protection for students who have or intend to have children during schooling. As medical schools increasingly focus on student wellness, an important consideration is the family planning intentions of students. For example, flexibility in scheduling or financial support for pregnancy or ART could be made available.
The cost of medical education has increased by about 750% from the 1960s to 2018 and many students incur a substantial debt burden during medical school. 37–39 This, combined with the costs associated with child-rearing, 40 can be difficult for students and early career trainees. Assigned female at birth and LGBTQ+ physicians are also more likely to incur substantial costs of family building through ART, adoption, and surrogacy. A recent study of surgeons found that the costs of ART, adoption, and surrogacy are often greater than $40,000. 19 Both self-identified female and LGBTQ+ students in this survey identified unique barriers and concerns in free response form. There are also large disparities in access to infertility services in the general population. 41–43 Although there has not been a comprehensive study of student access to or student health insurance coverage of ART, students likely face similar access issues as the general population.
In addition to cost concerns, most medical schools lack parental leave policies for their students. 44,45 Medical students in their clinical years, in particular, work similar hours to resident physicians, and are also likely to face similar issues with childcare and lactation support. 1 Medical students have successfully championed protections for parenting students, 46 but broader guidance on best practices for parental leave policy from national organizations like the Association of American Medical Colleges would be beneficial. 4,47 Previous studies of parenting medical students have emphasized the need for flexibility and supportive administration. 48 Other solutions proposed for residents, including expanding access to lactation rooms 1 and on-site childcare, 49 should also be made available to medical students rotating at those training sites. In addition to supportive policies at the school and national organizational levels, students need education about the resources and rights available to them. For example, many students are interested in hearing about parental leave policies during residency interviews, but this information is not frequently presented. 50
Efforts to improve policies and education are important because perceptions of family building support have implications for students’ future careers. For example, students may be discouraged from pursuing surgical training because of concerns over balancing a demanding residency and parenthood. 51,52 There are also concerns about stigma surrounding pregnancy or parenthood in residency training, which has been most often identified in surgical specialties. 3 These sentiments were echoed in the free response portion of the survey.
In addition to institutional policies and programs to support students, there is a widespread need for education regarding fertility. A significant portion of respondents had gaps in knowledge about age-related fertility decline and male factors in infertility, which is consistent with previous research on students and residents. 26–31 A majority of medical students in this survey had not received formal education on infertility, ART, or oocyte cryopreservation, which has important implications not only for their personal knowledge but also for their ability to counsel future patients. Additionally, many students were interested in pursuing ART or oocyte cryopreservation but cited a lack of knowledge about the process as a barrier. Previous research has shown that brief educational interventions can increase medical student knowledge on these topics, 32 and should be implemented more broadly across medical school curriculums. Education earlier in medical and premedical curriculums can empower students to make informed career and family planning decisions.
Limitations
Limitations of this study include self-selection bias in survey participants. Those with concerns about family building and fertility may have been more likely to participate. A higher proportion of participants self-identified as female and medical students. Students who identify as LGBTQ+ were also underrepresented in the sample. Furthermore, there are many topics that this study did not explore in a comprehensive manner and should be researched further, including but not limited to: surrogacy, adoption, miscarriage, concerns about pregnancy complications and/or neonatal outcomes, and changes or special considerations given the COVID-19 pandemic and new virtual interviewing environments.
Conclusion
Premedical and medical students have similar concerns about parenting and fertility as physicians. Most students do not feel supported in parenthood and there are many opportunities for education and policy improvement at the medical school level, including well-defined polices and flexible scheduling. Policy improvements should take into consideration all forms of family building, including ART, adoption, and surrogacy. There are major gaps in the literature on the experiences of underrepresented students in particular, and future research into the needs of these groups should be a high priority.
Acknowledgments
The authors wish to thank all survey participants for their time and insight on this important topic.
Footnotes
Author Contributions: Nicole Vestal, MD: Study idea, study design, data collection, data analysis, manuscript drafting, manuscript review; Kelby N Hunt, BS: Study design, data collection, data analysis, manuscript drafting, manuscript review; Morgan S Levy, BS: Study idea, study design, data collection, data analysis, manuscript drafting, manuscript review; Maya Roytman: Study idea, study design, data collection, data analysis, manuscript drafting, manuscript review; Alissa Mossbarger, BS: Study idea, study design, data collection, data analysis, manuscript drafting, manuscript review; Intira Sriprasert, MD, PhD: Data analysis, manuscript drafting, manuscript review; Sharon Winer, MD: Study idea, study design, data analysis, manuscript drafting, manuscript review.
Conflicts of Interest: None declared
Funding: None declared
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