Physician infertility: a structured literature review

Abstract

Physician infertility has become a growing concern because of the increasingly high rates of infertility physicians experience associated with their strenuous work schedules, environmental exposures, and delayed family planning due to their necessitated years of training. Fortunately, there has been an increase in awareness, advocacy, and urgency for institutional support alongside this suboptimal association. This awareness is reflected in the vast existing literature regarding physician infertility; in this scoping review, we aggregated and assessed the current data as well as identified gaps in the available research. Including 56 articles regarding various aspects of the current state of physician infertility, we compiled and synthesized the available data to understand the role of infertility in physician family planning, including specific analyses for surgeons and comparisons of male and female physicians. We discussed the utilization and downsides of artificial reproductive technologies for this population in terms of finances and logistics, contributing to this complex and, until recently, neglected issue. Lastly, we reported on a multitude of suggestions aimed at medical training programs to help combat the complex issue of physician infertility.

Background

Infertility, defined by the American Society for Reproductive Medicine, refers to the inability of a person to “achieve a successful pregnancy based on [their] medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors” [1]. Infertility plaguing physicians, specifically “physician infertility,” directly impacts both male and female doctors deeply as well as transgender physicians, single physicians, and physicians with same-sex partners, warranting comprehensive research to investigate the topic [1]. This reproductive problem has become an ever-growing concern within the medical field due to various factors such as the demanding work schedule, long working hours, exposure to harmful substances, and delayed family planning to accommodate arduous training programs [2]. Although many healthcare professionals experience these risk factors, this phenomenon of observed infertility appears to be largely exclusive to physicians as described in the literature. Hospital employees in general were shown to have higher live birth rates (76.1 vs 69.6% p = 0.042) and equal rates of infertility compared to the non-healthcare workers, indicating that infertility may not be a generalized problem for healthcare workers but rather something unique to physicians [3]. In recent years, many have advocated for greater awareness of physician infertility and the implementation of policies to support physicians in their family planning efforts.

Commonly identified themes of anxiety regarding infertility, conflict between career and family building, and financial concerns were persistent across articles when assessing physicians’ views on starting families. The duration of medical training and long duty hours were found to be the most common factors that influenced the timing of childbearing among medical professionals, with 65% of male and female responders concerned about their future fertility [4]. More specifically, in a survey sent to female radiation oncologists (n = 126), 58% of the respondents delayed or are currently delaying pregnancy or adoption, citing the reason to delay as to accommodate the demanding annual schedule of exams required for board certification [5].

Compiling data from many studies, infertility has been documented to affect 24.1–33.0% of physicians [5–10]. Collectively, these studies surveyed 3153 physicians across various specialties, and they starkly contrast with the national rate of infertility of 13.4% [11]. The high prevalence of infertility among physicians, as evidenced by the aggregated data from these studies, highlights the need for greater awareness, support, and research to address the unique challenges faced by medical professionals in starting a family.

This is a widespread problem, affecting trainees at all stages of medical training due to the inherent planning necessary for ideal family planning. With 43.2% of practicing female attendings that were surveyed explicitly stating that they would have changed their family planning (including timing of conception during training, choosing a specialty that is more compatible with their familial priorities, or utilizing fertility preservation techniques), it is imperative to enhance our working knowledge and systems in place to support trainees building families [8]. Additionally, data has demonstrated that female residents had 2.89 times increased odds of having 0 children (p < 0.0001) [12]. Despite having such increased odds of bearing no children, female residents faced only 58% decreased odds of being married (p = 0.0003) [12]. While much of the literature on the topic of physician infertility focuses on those in residency training, one study aimed to address attending physicians by obtaining reported outcomes of family building years later [8]. With 327 respondents, 82.0% (n = 268) of the subjects were parents; 77.4% had biological children with an average of 2.3 children [8]. On average, these parents had their first pregnancy prior to finishing their completion of training (the average age of completion of training was 31.6 years of age, whereas this study population’s age at first pregnancy was 30.4 years old) [8].

Not only is infertility seen at higher rates in physicians compared to the general population, but the stigma and tribulations associated with infertility also serve as a source of stress. This added stress of an infertility diagnosis may be even more threatening for female physicians, who are already at higher risk of burnout compared to their male counterparts due to implicit challenges with work–life balance and stemming from gender bias [6]. Thus, it is important for healthcare institutions to recognize and address the impact of infertility on physicians and provide them with the necessary support and resources to manage this challenging experience.

To conduct this analysis, we utilized PubMed and Google Scholar databases to find relevant articles. We included the MeSH keywords to guide the literature review: “physicians,” “infertility,” “medical residencies”. We only included articles written in the English language. Primary research, including randomized control studies, survey-based inquiries, and retrospective investigations, as well as secondary reviews, was included in our assessment of the literature. The observation interval searching for articles for inclusion was from April 2023 to April 2024.

Focus on OBGYN trainees

There was also a distinct subset of research aimed toward residents in obstetrics and gynecology (OBGYN). Studies focusing on these trainees demonstrated the following: 75.8% of residents wanted children but had not started childbearing; 84.5% reported delaying childbearing for career/educational reasons; 40.8% of the respondents considered fertility preservation [10, 13]. OBGYN residents and fellows both greatly claimed worries about infertility (78.5% vs 91.3%, p = 0.01; OR 2.74, [95% CI 1.24–6.04]) [10]. Lastly, 29.3% of the resident respondents experienced infertility at a rate of 29.3%, and 36.3% of this subgroup reported stigma associated with their infertility [10].

Perhaps unsurprisingly, despite the setbacks that reproductive-focused residents face themselves, they have been found to be more supported than their non-reproductive peers [14]. Further, OBGYN residents reported feeling “somewhat supported” or “very supported” by their program to pursue family-building goals compared to residents of other specialties (83.5% vs 75.8%, OR 1.62, 95% CI 1.23–2.14) [14]. While this reported feeling of support among OBGYN residents is promising, this sentiment is not widespread among all specialties.

Focus on men’s health

While the scope of current literature focuses predominantly on female physicians, few studies have ventured into this pertinent men’s health issue as well. The sole attempt to investigate solely male physicians’ infertility assessed 226 men, underscoring the need to be inclusive in investigating physician infertility as it pertains to all genders [15]. In this survey-based study, the majority of male surgeons reported fathering biological children, with an average age of first childbirth at 32.3 years of age [15]. This population denoted difficulty with fertility at a rate of 26.6% (n = 47), and of this population, 31.9% of male surgeons sought out ART with their partners (n = 15) [15]. Because these findings deviate from female-specific data, male trainees may be able to partially circumvent these fertility challenges compared to their female counterparts.

Though, historically, infertility research has had a focus on advanced maternal age, a growing body of literature has shown that advanced paternal age also has detrimental effects on a couple’s ability to conceive [16]. Thus, the tendency to delay childbearing in favor of medical training greatly affects both male and female trainees, alike. Further, in a recent study assessing 235 male physicians, 23.4% of the respondents had actively sought out or were considering seeing a physician for fertility evaluation [17]. This finding underscores the persistent fertility concerns across gender.

Focus on surgery

The job of a surgeon is both intellectually and physically demanding and requires the longest residencies of all physician specialties. It is no wonder that surgeons report delaying childbearing due to training (64–65% of female surgeons and 43.5–43.7% of male surgeons), having their first children 5–9 years later in life than the average adult (30–34 years old vs 25 years old), and having fewer total children in general (estimates range from 0.6 to 2.1 children compared to the national average estimates of 2.3–2.7 children) [7, 18, 19]. Compared to physicians in non-surgical specialties, surgeons tend to be slightly older at first pregnancy (32.1 vs 31.7 years, p = 0.0050), work longer hours (62 vs 52 h/week, p < 0.0001), and have more preterm births (23% vs 20%, p = 0.0491) [20]. Moreover, infertility rates for female surgeons remain on the high end of physician infertility. While overall physician infertility is in the range of 24.1–33.0%, studies indicate that surgeons are particularly susceptible to fertility issues. In a survey of 1021 female surgeons, the highest rates of infertility were reported by female otolaryngologists (29%), with another study showing infertility rates as high as 33% for female plastic surgeons [21, 22].

The surgical lifestyle appears to be particularly inhibitive to childbearing for female surgeons compared to their male counterparts. In a survey of female surgeons (n = 698) and male surgeons (n = 161), female surgeons had fewer children than male surgeons (1.9 vs 2.4, p < 0.001), and, on average, female physicians had their first pregnancy at 2 years older than the female (non-physician) partners of the surveyed male surgeons (33 years old vs 31 years old, p < 0.001) [19].

Many reasons for this disparity have been both reported and speculated. Some are not specific to surgery such as the fear of negative judgment by peers and administration, overly optimistic views of postponing fertility, and lack of paid maternal leave [18, 19, 21]. Nonetheless, compared to physicians in non-surgical specialties, surgeons experienced more frequent negative attitudes toward pregnancy in the workplace (54% vs 48%, p < 0.0001), less support for pregnancy and breastfeeding (58% vs 66%, p < 0.0001), and shorter maternity leave (8.6 vs 10.9 weeks, p < 0.0001) [20]. In fact, formal maternity/paternity leave was reported by only 36.54% of program directors in a survey of 88 plastic surgery residency programs [23].

Surgical work culture and requirements especially have devastating consequences on the pregnant surgeon’s health. Compared with non-surgeon females, female surgeons took less time off for bed rest during their pregnancy (36.1% vs 22.1%, p = 0.005) [24]. Moreover, exposures to radiation, surgical smoke, and anesthetic gasses may also put female surgeons at an elevated risk for infertility and pregnancy complications [25]. This is particularly concerning when one-third of all surgeons are female, a number which could be increased further given more support from training programs and peers for female surgeons when it comes to family planning, pregnancy, and infertility treatment [26].

A global phenomenon

The literature reveals, though, that this is not an isolated occurrence: there is a ubiquitous systemic concern of infertility among physicians globally. Notably, other North American countries share similar phenomena: physicians giving birth to their first child at later ages (average age of 32 years old), specialty choice impacting family planning habits, widespread concerns of future fertility, and higher rates of maternal morbidity compared to their non-physician counterparts [27–29]. Another study out of India reports familial and societal pressures as positive factors for pursuing pregnancies; however, the reality of strict schedules and support from faculty and colleagues function as negative influences on their decisions [30]. Lastly, a study from the UK cites an overwhelming majority of surgical trainees expressing regret in delaying attempts to conceive children due to “training” (80%, n = 416) [31]. The global medical community faces systemic concerns and realities of infertility among physicians, with similar patterns of high rates of infertility as well as increased anxiety regarding future fecundity in these professionals.

Physician pregnancy complications

Pregnancy complications related to physician work duties and environments are both feared and a reality for many. In a study of 850 surgeons, nearly twice as many female surgeons as female partners of male surgeons experienced pregnancy complications (48.3% vs 27.2%, p < 0.001). Those female surgeons were also more likely to experience non-elective C-Sects. (170 of 692 [25.5%] vs 24 of 158 [15.3%], p = 0.01) and musculoskeletal issues (255 of 692 [36.9%] vs 29 of 158 [18.4%], p < 0.001) [18]. However, little difference was found in preterm delivery between female surgeons and non-surgeon females (15.2% vs 18.3%, p = 0.51) [18]. A systematic review of pregnancy complications in surgical residents and surgeons demonstrated that the complications that were more prevalent in surgeons than the general population were miscarriage (11.0–28.0% vs 4.2–13%) and placental abruption (2.0–5.2% vs 1.2%) [7]. Pregnancy complications extend outside of surgical specialties; 31.7% of female oncologists revealed having had a miscarriage (n = 1004), higher than the estimated miscarriage rate of the general population (26%) [25, 32]. Of special interest, longer physician work hours were found to increase pregnancy complications with a 1% increase for each additional hour of work per week (1.01, 1.006–1.02, p < 0.001) [20].

Physicians are at risk for not only physical complications of pregnancy but also mental health complications as well. In a survey study, postpartum depression was more common in female surgeons than female partners of male surgeons (77 of 692 [11.1%] vs 9 of 158 [5.7%], p = 0.04), and, after controlling for demographic factors, practice setting, and workload, was found to be related to pregnancy complications [18]. The discrimination female physicians experience before, during, and after pregnancy may only exacerbate complication-related depression. In a survey of 4533 female physicians, 42% recall being discouraged from having children, and 49% recall negativity toward pregnancy in the workplace [20]. In another study, 32.1% of female oncologists (322 of 1004) affirmed experiences of discrimination for being pregnant, and 33.1% additionally reported discrimination over taking maternity leave. 17.9% claimed that they were either explicitly told or felt pressured to end their maternity leave early [25]. Plastic surgery residents in a separate study reported more support from faculty than fellow residents, which could be due to resentment from residents who must cover for another resident when she goes on maternity leave [22]. Measures should be taken by programs to reduce unnecessary stressors to create a healthier work environment for pregnant surgeons.

Assisted reproductive technologies (ART)

Assisted reproductive technologies (ART) are any method of manipulating either egg or embryo to either improve outcomes of conception or to preserve fertility for those not yet ready to conceive [33]. ART is a viable, although imperfect, option for physicians who have had to postpone childbearing due to career-related concerns. Physicians both seek the help of ART (18–28% vs 5.2–12%) and conceive through ART (8–13% vs 1.7%) at higher rates than the general population [7, 19, 34]. In particular, female surgeons use ART at higher rates than male surgeons (25.2% vs 17.4%, p = 0.035, n = 859) [19]. These observed findings may be due to a physician’s increased awareness of available treatments or due to a stronger need for these medical procedures; perhaps, it is a combination of these theories. Among physicians facing infertility, the use of in vitro fertilization (IVF) is the ART method most commonly cited in the literature. Rates of IVF were at 21.6% (40 of 176) for female surgeons that tried ART and 57% (8 of 14) for OBGYN residents [10, 21].

However, not all physicians who pursue ART do so because they cannot conceive. Some may wish to give themselves the best chance at future fertility by using fertility-preserving ART, such as oocyte cryopreservation. One study found that as few as 5.3% of female oncologists (n = 1004) had used oocyte cryopreservation [25]. However, a much higher number of physicians would consider using oocyte cryopreservation (57.8% of female residents, n = 2,828), suggesting that there are barriers to actualizing the preservation itself unrelated to a lack of awareness or desire [14]. Among those physicians diagnosed with infertility and who have tried to conceive, 16.7% (n = 60) said, in retrospect, they would have used cryopreservation [8]. However, a potential concern of lack of a suitable partner and restrictions on desired family size pose as restrictions for physicians contemplating oocyte preservation.

Overall, female physicians who have used ART successfully report being just as satisfied with their pregnancies as female physicians who have conceived naturally with or without having had fertility issues [21]. Therefore, residency programs and medical practices can support their physicians who are struggling with infertility by providing awareness and education on the utility of ART, encouraging young physicians to consider their options early in their training and providing an understanding of insurance coverage options.

Barriers to addressing physician infertility

Costs

While ART utilization seems to be a promising solution for overcoming physician infertility, it is quite financially and logistically cumbersome, barring many from accessing these treatments. One study found that one-third of female surgeons who utilized ART had spent over $40,000 to try to conceive a child [19]. When accounting for the high prices of ART treatments, it becomes apparent how quickly these expenses can add up over multiple cycles, if unsuccessful. A single cycle of IVF (i.e., egg retrieval, insemination, and cryogenic storage) is estimated to cost anywhere from $12,400 to upwards of $20,000 [35]. Many women will need to complete more than one cycle, and some even need several cycles before achieving a successful pregnancy [36]. Finally, oocyte cryopreservation with 5-year storage is estimated to cost around $15,000, which does not even include the cost of oocyte thawing once a woman is ready to conceive [37].

These costs are especially intimidating when most physicians are still in residency or fellowship during their prime childbearing years. As of 2022, the average entering resident is $202,450 in debt from medical school alone and begins to make monthly payments on those loans 6 months after graduating medical school [38, 39]. With the average first-year resident earning around $60,000—a salary that does not increase much until the resident completes training and begins work as an attending physician—without insurance, infertility treatment is hardly attainable for medical residents and fellows [40]. Some medical training programs have attempted to reduce this burden by providing infertility insurance coverage for trainees, although infertility insurance coverage is highly variable between programs and often insufficient. In a 2020 study, an insurance summary of benefits from 24 US and Canadian andrology and reproductive endocrinology and infertility (REI) fellowships was obtained to compare institution-based infertility insurance coverage for fellows [35]. The results indicated no consistent trend among these institutions. 62.5% (15 of 24) of the programs offered coverage for infertility treatment although with average lifetime caps (officially termed “lifetime maximums”) of $16,100 [35]. A quarter of programs (6 of 24) only offered coverage for purposes of infertility diagnosis [35]. Male factor infertility and sperm retrieval were only specifically mentioned in one-quarter of the insurance benefits as well. Even fewer policies offered coverage for oocyte cryopreservation (2 of 24 [8.3%]) [35].

Variability in infertility insurance coverage between institutions persists for physician faculty after training. An online search of infertility insurance policies at various OBGYN academic institutions yielded a lifetime maximum average of $23,076 with some institutions offering no infertility coverage at all to one offering a lifetime maximum of $100,000. Although state mandates for infertility insurance coverage currently exist in 19 US states, total coverage is highly employer-dependent and does not benefit physicians training and practicing in more than half of US states [35, 36]. With so many unknowns, it is difficult for a medical student to begin preventing and planning early for the possibility of infertility. Once that medical student is matched into a residency program, the ability to afford treatment is not guaranteed.

Even if the cost of ART is not an issue for the physician struggling with infertility, then the time required to carry out ART may be. When OBGYN residents who had sought infertility treatment were asked whether they had some or great difficulty attending appointments, 61% answered yes (n = 18) [10]. IVF in particular is a multi-step process that includes oocyte retrieval, in vitro fertilization, and embryo transfer into the uterus. Additionally, some treatment courses may require preimplantation genetic testing and sperm retrieval [33]. The packed and shifting schedule of residents and fellows may make it difficult to attend appointments for infertility diagnosis and treatment and may make adherence to hormonal injections required for IVF treatments unreliable.

Psychological obstacles

Moreover, infertility treatment itself is an emotionally arduous process described as having a “roller-coaster effect” due to the numerous steps during treatment that must go successfully to advance to the often-unpredictable embryo implantation stage [41]. Considering the elevated stress levels and high burnout rates prevalent during residency, many physicians may not want to put themselves through such emotional hardship and may postpone infertility treatment to a point in the future when they are older and when treatments are less likely to be successful.

Therefore, infertility treatment can be both life-altering and complex—a complexity which is only exacerbated when physicians are educated so little on infertility and treatment options. Several studies demonstrate that physicians of all specialties have difficulty answering basic questions about both female and male infertility incorrectly. Less than 1% of 2828 physicians from various specialties answered all questions correctly on a survey that tested knowledge on fertility and oocyte cryopreservation [14]. Most physicians were able to identify the age of prime female fertility (72.7%), but only half were able to identify age 35–39 as the age where female fertility significantly drops [14]. Another study found that physicians tended to underestimate the probability of conception, especially at younger ages, but tended to overestimate the probability of conception for a woman with access to treatment for her fertility issues [8]. Surprisingly, two separate studies demonstrated that OBGYN trainees were no more likely than non-OBGYN trainees to answer fertility questions correctly (n = 2475) [12, 14]. When surveyed, 65.7% of female oncologists agreed that medical school and residency should involve discussions about fertility preservation (n = 1004) [25].

Lack of education

Moreover, fertility education for physicians appears to be substantially more focused on female fertility than male fertility. There is a long history in medicine of avoiding the topic of male-factor infertility. While more people today are discussing male infertility, it is likely some of this stigma remains and continues to influence medical education [42]. In a survey of 350 medical students, residents, fellows, and faculty, questions about female fertility were answered correctly by 56% of participants, but questions about male fertility were answered correctly by only 12% of participants [4]. Knowledge gaps in male infertility exist even among urology residents. In one study, 80% of surveyed urology residents felt their exposure to andrology, and male infertility during residency was inadequate (n = 100), and 75% of urology residents in another study claimed that less than 10% of their training involved male infertility (n = 72) [34, 43]. This information suggests that much effort will have to be made henceforth to support males in finding treatment for infertility.

Culture of medicine

Lastly, the overall culture and lifestyle of physician training sets physicians up for failure when it comes to preserving their fertility. Residents often face large clinical workloads and night shifts, which have been associated with impaired fecundity [9]. Although a stringent schedule has been linked as a risk factor for infertility, it is so deeply ingrained into our residency programs, leaving trainees with little options for enhancing their family planning capabilities. Shift work has been linked to negative systemic consequences, notably decreased fertility [44]. As shift work schedules are an integral part of medical training and often for attending physicians, this is of particular concern for those entering the medical profession.

Moreover, a culture that emphasizes postponing family planning for one’s medical career generates an atmosphere of lacking pregnancy support during training. Pregnancy support can differ between peers and program directors, and it can be gleaned from the availability of maternity and paternity leave or program insurance policies. Female residents tended to recall less support than male residents from their programs when it came to having children (75.7% vs 79.7%, OR 0.79, 95% CI 0.65–0.96, p = 0.020); however, in this study, the majority of both genders experienced support from their programs [14]. While this deviates from other studies regarding physician support, this highlights the inconsistency among residency programs to create positive environments for their physicians desiring to start families. Regardless of gender, restricted maternity and paternity leave, stigma toward infertility, and attitudes toward pregnancy from peers are all areas that appear to be acting as barriers against overall perceived support.

Greater implications of fertility

The implications of fertility extend beyond an individual’s desire to have children. Fertility can impact an individual’s physical, emotional, and social well-being; the greater implications of the inability to conceive can cause significant emotional distress and may lead to depression, anxiety, and a decrease in overall quality of life [45]. Fertility issues can also result in strained relationships with partners and loved ones, as well as contribute to perceived social isolation and stigma [46]. Additionally, women facing infertility, or even the potential of infertility, face grief, anger, and guilt at higher levels, leading to greater impacts of coping with their medical stressors [47]. This paradigm contributes to an onerous biopsychosocial model, highlighting how one’s well-being may falter with the onset of infertility.

Fertility, or the lack thereof, has strong effects on one’s career. Because the timing of medical training often coincides with the ideal time for childbearing, conflict manifests between one’s career and personal goals [48]. The well-being of physicians includes their reproductive health, which involves the ability to start a family at a time of their choosing [2]. In a comprehensive study aimed at female radiation oncologists, we noted that women who delayed childbirth to accommodate their board examinations were significantly more likely to face infertility than their colleagues (46% vs 18%, p = 0.008) [49]. This decision, for most, was not taken lightly as these physicians cited that “full board certification had a significant effect on achieving academic promotion or professional partnership (52%), annual compensation (54%), and nonclinical professional commitments (58%)” [49]. This emphasizes the need many physicians feel to put personal lives on hold to prioritize their career, risking their window of fertility simultaneously [48]. Even further, female physicians may feel an increased pressure to delay childbirth in favor of their career due to financial incentives, as they have been shown to be undercompensated compared to their male counterparts [25]. Physicians, especially women, may feel pressure to delay childbirth to prioritize their careers, with this decision causing significant impacts on their fertility.

Gaps in research

While our structured literature review has certainly brought up many facets regarding greater physician infertility, our search has identified multiple shortcomings. Firstly, there is a stark lack of research on male physician infertility compared to the extensive literature revolving around varying specific female populations within the medical field. This scarcity of knowledge regarding men’s health creates discrepancies between genders, despite infertility being a pervasive challenge for both men and women. The greater implications of this research deficit are overwhelming; male factor infertility is associated with many overall health comorbidities, indicating the importance of research to find the root of the problem [50]. By having a greater knowledge of male physician’s infertility, we can combat these discrepancies, supporting all physicians from the beginning of their fertility journey.

Similarly, while efforts focused on oocyte preservation and ART techniques, there was little focus on collecting sperm cryopreservation data. Currently, sperm cryopreservation is considered the “gold standard” for male fertility preservation [51]. Because of this, men who are expecting to delay their family planning efforts should strongly consider utilizing sperm cryopreservation techniques to prolong their fertility capabilities. This lack of research into the topic indicates a lack of awareness, and in turn, underutilization among male physicians. With a lack of information on both infertility and preventative efforts, male physicians are left without adequate data regarding their future fertility status upon entering this strenuous field.

Lastly, we identified a substantial lack of data of primary care physicians; the literature greatly focuses on strictly surgical subspecialties and OBGYN. Although surgical specialties are perceived as more stressful than primary care and thus may lead to higher rates of infertility because of this, this is not exclusive to surgery [52]. Thus, future research would be more comprehensive by including more specialties in its analysis.

Future suggestions

Given these threatening realities of infertility for physicians, we have accumulated future suggestions for the field and for individuals beginning their medical training. Broken up into broader categories, we have observed the following recommendations: a call to action for changes in residency programs, longitudinal educational initiatives geared toward trainees, and a need for greater support for family planning. Regarding residency programs, researchers have proposed more defined maternity and paternity leaves, greater flexibility in scheduling work, access to childcare, and breastfeeding allowances [23]. Additionally, this scoping review has highlighted inconsistencies among residency program benefits. Many articles advocate for widespread implementation of insurance coverage for and access to fertility assessment and management to aid with the financial burden of pursuing a family [2]. One of the biggest barriers in combating physician infertility is the large financial burden associated with ART; by providing more comprehensive insurance options, medical residents may be empowered to pursue a greater variety of fertility treatments. The financial aspects of infertility are particularly important to this population as residents are typically inundated with school debt as well as lower salaries [52]. Lastly, regarding suggested changes to residency, we have noted advocacy for more robust and standardized maternity leave. Research has shown that the length of maternity leave was strongly correlated with respondents’ level of overall satisfaction, with an overwhelmingly positive response from those receiving more than 8 weeks off (p = 0.002) [24].

A cost-effective strategy to raise awareness and knowledge regarding fertility is implementing a longitudinal educational program for trainees. These educational sessions can provide information about available fertility preservation options, allowing medical trainees to make well-informed decisions regarding their fertility future [4]. However, it is important to acknowledge that this problem is not exclusive to residency programs; these issues are present for medical students who are starting their training as well. This is exacerbated by the increasing age at matriculation for medical school [53]; with the aging population of medical students, we are likely to see more medical students starting families during their studies, making fertility education at this stage increasingly important [48]. Further, data shows that perceived workplace support for pregnancy was over 20% less in medical school compared to those who had their first pregnancy in residency (p = 0.02) [8]. This lack of support contributes to the notion that efforts directed toward combating physician infertility need to start during medical school.

A tangible way for medical training institutions to maintain support is through the implementation of counseling for this population [47]. Physicians experiencing infertility may adopt maladaptive strategies to cope with their attempts to conceive, warranting an urgency for counseling services, if wanted. If medical schools and residency programs were equipped to provide counseling options to trainees experiencing infertility, it could serve as a critical means of support to help them navigate this challenging experience and promote their overall well-being.

Although one’s career was most commonly cited as the reason for delaying childbirth, data show that prioritizing training over family planning through this postponement does not yield higher wages [49]. Thus, this perceived major incentive may be a false pretense as it may be assumed that prioritizing training over family planning would lead to higher earning potential in the future, but the data suggest otherwise. It appears that with less reward for prioritizing one’s career, there is less of an argument in favor of prioritizing one’s career while risking fertility.

With these suggestions, we hope to help foster a healthy and supported medical workforce for future generations. As other fields have adopted a more substantiated approach to family planning, the medical field demonstrates considerable setbacks in their support of trainees [48]. In order to create a more equitable training environment, we hope to see many of these suggestions implemented to better alleviate some of the burdens of conceiving during medical training.

Conclusions

As a physician’s reproductive health is vital to their overall well-being, the risks and subsequent management of infertility should be studied and addressed from policy and advocacy standpoints. Though ART advances have created more opportunities for those suffering from infertility, they are also a challenge for physicians to employ due to their high costs and arduous processes. More education, research, and support need to emerge to ensure that young men and women can choose a medical career and specialty freely without overwhelming concerns about their ability to form a future family. This is especially noteworthy as medical students take more gap years and come from non-traditional paths that leave them older at graduation [53]. Moreover, these efforts must extend throughout a physician’s fertility journey starting at the family-planning stage and continuing through pregnancy and beyond. It is crucial that medical training institutions implement measures to reduce unnecessary stressors, creating a healthier work environment for pregnant physicians and those struggling with infertility alike.

Funding

None.

Data availability

Data regarding any of the subjects in the study has not been previously published unless specified. Data will be made available to the editors of the journal for review or query upon request.

Declarations

Competing interests

The authors declare no competing interests.