“The elephant in the (exam) room”: pregnant reproductive endocrinology and infertility physicians’ experiences in clinical care

Abstract

Objective

To determine the impact of being pregnant while working as a reproductive endocrinology and infertility (REI) physician.

Design

A qualitative study based on semistructured interviews conducted between March 2021 and January 2022.

Subjects

Twelve US REI physicians who were recruited through purposive sampling.

Exposure

Experience of pregnancy while providing patient care in an infertility clinic setting as a fellow or attending.

Main Outcome Measures

Qualitative thematic analysis of interview transcripts to produce basic codes, organized into subthemes and themes.

Results

Respondents experienced pregnancies while practicing infertility medicine in 11 states. Five reproductive endocrinologists used assisted reproductive technology to conceive their own pregnancies. A majority discussed how increased awareness of the fertile window and potential pregnancy complications impacted them. Most acknowledged that seeing a pregnant physician could be difficult for a subfertile patient and took steps to protect the patient, including intentionally trying to hide physical manifestations of pregnancy via clothing or scheduling. Emotional experiences discussed included: anxiety about their own pregnancy, self-consciousness of physical manifestations of pregnancy or personal fertility journey, survivor guilt related to conceiving while their patients struggle and anxiety over patient interactions. The majority noted patient-initiated conversations about physician pregnancy and described these as positive interactions. Many reported dialogues with colleagues or mentors about personal family-building and its impacts on patient interaction.

Conclusion

This study highlights the need for improved support for personal family building within the REI field. Opportunities for improvement include maternity leave, collegial collaboration, and guidance for management of challenging patient interactions. Improvements in these areas have the potential to result in improved support, empathy, and clinical care for REI patients and physicians.

The reproductive endocrinology and infertility (REI) workforce has historically been comprised of more male than female providers. Recently, however, the balance has shifted to a female-led specialty (1, 2, 3). The extended reproductive medicine training that REI physicians receive after completing Obstetrics and Gynecology residency training may delay personal reproductive choices such as childbearing (4). As a result, it is not uncommon for female REI physicians to provide infertility care while navigating their own pregnancies.

The emotional challenges that patients face during infertility care, including hopelessness, guilt, emptiness, and anxiety, have been well-documented (5, 6, 7). Little is known, however, about the impact that a physician’s pregnancy may have on the provider-patient relationship or on physician wellness in this unique circumstance. Pregnancy in the context of providing medical care can certainly create unique interpersonal dynamics. A published narrative written by a maternal fetal medicine physician described the experience of caring for patients suffering pregnancy complications and losses while she, herself, experienced a healthy pregnancy. She recounted emotions including shock, guilt, disgust, and vulnerability, and questioned why she was able to avoid a devastating outcome whereas others were not. She wondered whether or not she should disclose her pregnancy to patients, given that some brought it up whereas others did not. Survivor guilt, a term used to describe the interpersonal process of surviving harm while others do not, was described as a framework for understanding these reactions and to help the physician speak more openly and clearly about these experiences with patients (8).

To date, survivor guilt and other experiences of the pregnant physician have not been deeply explored in relevant specialty care such as REI. This qualitative study is the first to provide an in-depth examination of pregnant REI providers’ experiences while caring for infertility patients. Research in this area will not only provide insight into pregnant physician needs, expectations, and experiences but may also offer important strategies to improve patient care.

Materials and methods

Study design

This qualitative study is based on in-depth, one-on-one semistructured interviews with REI physicians who experienced pregnancy as a fellow or attending while providing patient care in an infertility clinic setting. The study utilized Criterion-I purposive sampling (9). Participants were recruited both through the Society for Reproductive Endocrinology and Infertility (SREI) and social media platforms, including REI physician moms’ groups. The University of Iowa Institutional Review Board reviewed and approved this study (IRB# 202009119).

Interviews

An interview guide was formed by the investigators' experiences as professionals in Reproductive Endocrinology and Clinical Psychology. Core questions were explored with each participant and clarification was provided, if needed. Topics included experiences when participants were trying to conceive, experiences providing fertility care while pregnant, advice for other pregnant REIs, and beliefs about disclosure of a physician pregnancy to patients. Age, race, and ethnicity were not collected at the time of the survey to protect the anonymity of survey participants. The full interview guide is available in Supplemental 1 (available online). The study’s principal investigators and trained research assistants conducted semistructured Zoom interviews from March 2021 to January 2022. Informed consent was obtained before audio recording and interviews were subsequently transcribed verbatim. Interviewees did not receive any compensation for their participation in the study.

Analysis

Interview transcripts were thematically analyzed (10). A codebook was developed with inductive codes based on open coding from an initial transcript review and deductive codes based on the interview guide (11, 12). Four investigators individually coded transcripts and met to compare coding, discuss discrepancies, and refine the codebook. All transcripts were independently reviewed using the finalized codebook, after which investigators met to compare coding and resolve discrepancies. The final agreed-upon coding is presented in this manuscript. Illustrative quotes are presented verbatim, with articulated pauses (e.g., “like,” “um,” “right,” “you know”), grammatical errors, and identifying information (clinic names, locations, due dates) removed. Ellipses are utilized when a portion of the quote was removed to improve clarity. Similarly, brackets are utilized to add context to the discussion when not present directly in the quote (e.g. “it,” “they”). In both instances of ellipsis and bracket utilization, the concepts expressed in the original quotation are maintained.

Participant demographic characteristics were summarized using SPSS version 29.0 (SPSS, Inc., Chicago, IL). Descriptive statistics are reported as frequencies and percentages for categorical data and means and ranges for numerical data.

Results

Twelve reproductive endocrinologists who experienced a total of 25 pregnancies were interviewed. Physicians primarily conceived spontaneously (80%). Of the physicians who used assisted reproductive technologies (ART), one used intrauterine insemination (IUI) (8%), two used ovulation induction (OI) medications (16%), and three used in vitro fertilization (IVF) (25%). Gravidity ranged from 1 to 5, with a mean of 2.4. Live births ranged from 0 to 4, with a mean of 1.8. Two interviewees were pregnant at the time of the interview.

Four physicians (33%) experienced pregnancy during both residency and fellowship, whereas three physicians (25%) experienced pregnancy as both fellows and attendings, three (25%) solely experienced pregnancy as an attending, and two (16%) solely experienced pregnancy during fellowship. These pregnancies occurred in 11 U.S. states (MA, CA, PA, NY, MD, MO, IA, GA, OH, WA). Interviews had a mean duration of 29 minutes.

Thematic analysis

Framework analysis produced a matrix consisting of 42 codes, abstracted into four themes for the main outcomes: (i) patient centeredness; (ii) interactions with patients; (iii) clinic and professional environment; and (iv) personal emotional experience. Table 1 provides a summary of the findings arranged according to theme with illustrative quotes.

Table 1.

Mapped deductive themes and illustrative quotations from patients.

Themes, proportion (%) participants mentioned theme, description		Illustrative quotes, interviewee number (p)
1.Patient centeredness	1.1 Acknowledging seeing a pregnant physician could be difficult for a subfertile patient 2 codes within category Discussed by 100% of interviewees	It is hard because culturally we’re supposed to congratulate people on their pregnancies, I would say as a whole… so I know the patient felt that pressure and I [feel] so bad about that, having that additional stress even now.–2109
		I felt the same way [as infertility patients] when I was having my termination and my other friends who were pregnant at the same time continued to have their babies. And I feel like the word isn't really jealousy, but it is also jealousy, you know? It's like, “I wish I had that, but I don't wish I had your story, I just wish I had my own.”–2110
		I would find myself trying to hide the pregnancy, not wanting to inspire any kind of envy or unnecessary kind of sadness in the patient.–2111
	1.2 Taking steps to decrease perceived possible patient discomfort 3 codes within category Discussed by 92% of interviewees	As I got further in pregnancy, I definitely wore larger sized scrubs and used my white coat to try to hide the bump because I just felt guilty, and I didn’t want to put salt in the wound of these patients.–2101
		I would purposely wear larger scrubs, untuck my shirt, and stand not to accentuate my belly. What is different than residency, where I would wear flattering clothes for pregnancy,…[is] if I were wearing dress clothes, I wouldn’t have chosen something that accentuates my belly. I would wear a white coat and I would do things I didn’t normally do to downplay my growing belly.–2107
		I was trying to hide [my pregnancy] a lot in the beginning… I found myself sitting down at the desk, not standing up to greet them as much to hide the pregnancy, because I didn’t have a lot of trouble getting pregnant.–2102
	1.3 Increased empathy and understanding of the patient experience 2 codes within category Discussed by 100% of interviewees	The journey [to pregnancy] definitely helped me consider “Wow, this must be how [my patients] must feel all the time”, and it’s not usually after 6 months of this that they are coming to us, it is usually after 2, 3 years of [trying to conceive], and that’s just mind boggling because you are in this vacuum of stress, I can’t imagine going on with that for so long. -2111
		My attempts at getting pregnant changed the way that I take care of patients. … being infertile has made me a better fertility doctor, just kind of understanding some of the emotions and the anxieties and things that are triggering.–2105
		I think that [pregnancy] gives you more insight. When you’re in early pregnancy and [you’re thinking], “I really hope I don’t have a miscarriage. I really hope I don’t have one. I just had a cramp. I had some spotting.” With my first one, I had a little spotting, and I [thought] “This is so sad … this is a biochemical pregnancy, there’s no way to see anything on the ultrasound”… I definitely had the same tendencies as my patients when they call in [to say] “I saw a spot of blood!”…. I felt like it made me maybe even more empathetic towards my patients for having gone through that myself. Not through infertility but through early pregnancy [and] the rest of pregnancy and know[ing] how hard that unknown is.”–2107
		[Having a pregnancy and becoming a mom] made me more sympathetic to what [patients] were going through, it made me more empathetic to them, being a mom also forces you to be a more patient person… So, I think it made me a better doctor.–2102
		I definitely think I have a sense of the why it is so important to some people, and why some couples feel so urgent, because parenthood has been one of the greatest things that has ever happened to me… it was really after I became a parent myself, where I was like, “This is what they are working for, this is a really important thing.”–2103
	1.4 Redirecting conversations back to the patient 4 codes within category Discussed by 100% of interviewees	I would just be very brief about any acknowledgment …so a patient would say “oh, you know, congratulations” or something like that and then I’'d probably say something very briefly back.–2109
		“I would often try to redirect the conversation even when they were congratulatory and asking questions, I would answer one or two questions and then try to direct it towards [them] because they were there for their appointment.”–2101
2.Personal emotional experience	2.1 Survivor guilt and self-consciousness 2 codes within category Discussed by 92% of interviewees	”I think there is some amount of [survivor guilt], and that is why for me or any pregnant person in front of an infertility patient you hide the pregnancy, because you feel a sort of guilt and you don’ want anyone to feel badly during the encounter.”–2111
		“Why do I feel guilty?” And I think it is because I know that they are in pain every day from you know trying to become pregnant and trying to have a baby, and it was just sort of like putting it in their face.”–2101
		“That is just so unfair for this [patient who is not pregnant after 3rd embryo transfer] that this is where they’re at and here I am [pregnant].” -2105
		When I was pregnant there were times that I felt really guilty–I had finally kind of gotten to this goal, granted with my own trials and frustrations–but that I was there with this big belly and this baby on the way when you know that’s all that patient wants, so I was self-conscious about it.–2106
	2.2 Anxiety 3 codes within category Discussed by 100% of interviewees	Because of my history [of infertility & pregnancy loss] it was just pure terror the first time [I found out I was pregnant]… the number of times that I checked my hCG and did an ultrasound and checked my progesterone levels… it was like having a meth addict in a meth store.–2106
		At the same time very scared that if you do get pregnant, you’re going to have a belly with infertility patients and that for me was really hard, and something that I’m anxious about in the future.–2110
		I’m very worried about [how my pregnancy might impact my care of infertility patients] in the future as I go out and try to build a practice… I thought, “Oh no I’m going to make somebody upset or hurt their feelings and that sucks,” and moving forward I think, “How am I going to build a practice while trying to be pregnant?” And I think … “What about my timing, should I push it off, so that I’m not pregnant at the beginning of my career?” And then I think, “You did that once,” because I pushed off my second pregnancy to study for my boards “and then that didn’t end well,” so I feel like if there's anything your infertility patients have taught you, it’s that you get pregnant when you’re ready.–2110
	2.3 Positive emotions 1 code within category Discussed by 83% of interviewees	I’m hopefully [helping] accomplish a pregnancy for this person and being excited about my own.–2111
		I was very grateful. So many patients can’t get pregnant despite all the things that we do, … and I was grateful that it happened so quickly especially in light of the fact that so many of our patients have so much trouble and even if they’ve already had a baby before.–2107
	2.4 Protective coping strategies 2 codes within category Discussed by 92% of interviewees	Even though I knew it was going to be somewhat awkward at work, I still felt like I needed to do what I needed to do for my own family and for our family’s happiness, so I just proceed[ed]…–2103
		It’s obviously a unique situation or unique context to be providing care to women trying to get pregnant and being pregnant yourself, but again I do think it’s an important for both the patient and the provider to emotionally separate those things a bit.–2112
		We all have our lives and we have to live, and we have to have work-life balance, and we understand more than anybody the biological clock, and if it is time personally then … we have to take care of ourselves, while continuing to provide excellent care for our patients and that does not mean not having the family that you want.–2104
		[Pregnancy] is one of those things, if you want to have a family, you have to do it and you have to work, so it is kind of unavoidable, and like I said, … I felt guilty, but I don’t know that there is any way around it.–2101
3.Clinic and professional environment	3.1 Professional norms within medicine 5 codes within category Discussed by 92% of interviewees	I feel like as part of what we’re ingrained to feel in our professionalism that we develop in medicine is this feeling of always putting the patient first, and so I think that feeds into [that feeling of guilt] as well, that you are feeling like “oh I’m putting myself and my family first here,” which is ridiculous when you say it out loud, but in the midst of it you’re feeling like “this isn’t putting my patient first, this isn’t sharing their struggles.”–2109
		Certainly given the type of medicine that we practice, of course, we’re going to think about [how the patient will respond to our pregnancy] and I think over emphasizing it or bringing it up unnecessarily or things like that may not be beneficial or may be tough for patients trying to get pregnant, but overall, just with any female physician I would say that you know what you have to do.–2112
	3.2 Physician rights 2 codes within category Discussed by 75% of respondents	Physicians have a right to HIPAA and privacy as well. If someone doesn’t want to share a complicated pregnancy or maybe things that are going on, they don’t have to address them.–2111
		I think that reproduction is just part of the time of our lives that we are in training to become physicians, and we need to normalize that and support that as much as possible. There is no other time to have a baby for us and at the same time, every time is a good time to have a baby, and so I think that as a program director, I need to make sure that I set that tone for every single person here. … I need to make sure that we are supporting women … because I think it’s very unbalanced to think about changing someone’s educational curriculum around a pregnancy.–2106
	3.3 Lack of support at work or in training environment 4 codes within category Discussed by 100% of interviewees	I did have one instance with someone I was working with suggesting I cover up my belly when talking to patients … I already was wearing scrubs but from that point I really tried to shrink my belly away and that made me feel badly because my intention was never to make a patient feel badly that I was pregnant and they weren’t … That one interaction I had did really negative impact on me because it made me feel like I had done something wrong [by] being pregnant… and had made me feel very upset about my changing body, because pregnancy is a very visible thing. If I had diabetes you wouldn’t be like “you should try and look less diabetic.”–2107
		As a resident they actually gave larger white coats to one of the slimmer residents who was pregnant and very visibly showing so that she could hide her pregnancy a little more because they didn’t want to inspire that kind of sadness on their patients.–2111
		I think for the most part people were happy for me but I also think that in some ways it was [an] inconvenient for me to be pregnant during fellowship and I [got the] general feeling … that it would be distracting for patients to see a pregnant physician.–2106
		The fellowship director wanted me to do my research time while I was pregnant so as not to upset our infertility patients while I was that far along, so we ended up making a lot of changes to my clinical schedule to avoid having patients see a pregnant fellow.–2106
		We did not have a good plan in place ahead of time for when I was going on maternity leave. I asked multiple times, “What do I tell my patients?”, or “Who’s gonna be taking over?” and no plans were made…. It was like no one thought about it ahead of time, even though we had several months to plan.–2108
		There’s a reason why I did not pursue having a child in training, because I think that frankly 6 or 8 weeks off is BS, I think that there’s a limit of like how much time you can take off, so if you have two babies during fellowship you can’t take a single vacation to graduate on time. It’s really not a supportive environment for people having children, and for guys, and partners being able to take time off it’s nonexistent… I think it’s a really toxic parenting environment.–2105
		My maternity leave for my first baby was only 5 weeks and part of that was me because I thought that I should get right back, but really a young mom who hasn’t had a baby before really doesn’t know that you need longer than that, and really you need 3 to 4 months to really be home, and it is hard to explain that to people. Clinics could do better about, not only offering adequate maternity leave but making sure that these young moms take it, and that they take the time off.–2102
4.Interactions with patients	4.1 Positive and neutral interactions 2 codes within category Discussed by 92% of interviewees	I would say “thank you,” and we would move on.–2104
		I would say most patients, I would say probably 2/3 of patients don’t, half to 2/3 probably don’t acknowledge it and then and then the remainder you know if they do notice you know they they’re positive and they say congratulations.–2112
	4.2 Negative interactions 3 codes within category Discussed by 67% of interviewees	When I came in with the attending to follow up with her she just burst into tears and said, “I just want that to happen, and I obviously wanted that yesterday”, so I actually had to leave the room at that point.–2111
		One of the patients started tearing up she’s like, “You're probably one of those people that just gets pregnant when your husband looks at you.”–2111
		[Patients] would ask me pretty personal questions like if I had to go through fertility treatment or not, they would want to pat my belly for luck. [They would physically touch me] pretty often, at least once a week I would say once I was really showing.–2102
		[Pregnancy] definitely was part of the atmosphere in the room … I had to be more cautious of their feelings, be like a little bit more on eggshells, and other people were just excited because they wanted to get pregnant too.–2102
	4.3 Circumstances for provider disclosure 4 codes within category Discussed by 100% of interviewees	It wasn’t like we braced them for me walking in, or anything like that, that would be too much. I would walk into the room with the attending and sometimes they would say, “Oh, you are pregnant too?”–2110
		“The only time I have only brought [my pregnancy] up myself is as I prepare [my patients] for my leave.”–2103
	4.4 Opinion on provider disclosure of pregnancy 3 codes within category Discussed by 100% of interviewees	[Whether a provider should disclose their pregnancy to a patient is] a really hard question. There are two aspects to it, there’s the patients’ emotions and everything but the awareness and sensitivity. And then if you address it, I think you’re making it more of a thing than it needs to be. And maybe they wouldn’t appreciate that, maybe they don’t want to be treated differently and if they do, if they want to sulk about it or be sad about it, they don’t want to do it with you. They don’t want you to feel bad for them, I definitely never wanted anyone to bad about me.–2110
		I really think that [physician pregnancy] is not anybody’s business and so as long as their care is not interrupted, it really shouldn’t [matter]. I am 39 weeks pregnant, and I am still doing my retrievals, transfers, and scans and all that stuff, so, as long as my condition doesn’t impact their care, I feel like it is up to the doctor’s discretion to mention it or not.–2103
		I feel like bringing it up sort of like presumes that they’re gonna feel bad about it, but ignoring it also isn’t right, so I don’t know what was the best way to address that.–2108

Note: hCG = human chorionic gonadotropin; HIPPA = Health Insurance Portability and Accountability Act of 1996.

Theme 1: Patient centeredness

Participants discussed the various ways their pregnancy impacted patient care. They were quick to acknowledge that seeing a pregnant physician could be difficult for a subfertile patient and discussed taking steps to decrease or avoid anticipated patient discomfort. Several described heightened awareness that a physician’s pregnancy could be emotionally complex for patients experiencing infertility. This was observed in their discussions of pregnancy planning, self-consciousness about being visibly pregnant in clinical settings, attempts to physically hide their pregnancies, and consideration of possibly lying about requiring ART to conceive. They reflected on the cultural expectation to congratulate pregnant individuals, even when such gestures may be emotionally taxing for someone facing infertility.

Most participants discussed taking deliberate steps to reduce potential patient discomfort related to their pregnancies. Strategies included altering their appearance or presence in the clinic to conceal a visible pregnancy by wearing larger scrubs or white coats, adjusting body positioning, or sitting rather than standing to greet patients. Some participants limited in-person interactions by shortening visits, meeting virtually, or adjusting their call schedules. A few participants discussed planning pregnancies outside of clinical rotations (e.g., during a research year).

Overall, providers reported that their experience trying to conceive ultimately made them more empathetic toward patients, whether or not they, themselves, had been diagnosed with infertility. Many described feeling hyperaware of the potential of experiencing infertility or a pregnancy complication, isolated, and better able to relate to the emotional toll of infertility that patients experience. Even with years of training, they found themselves vulnerable to the same uncertainties, fears, and emotions their patients were facing. Some described ways that even relatively brief challenges could feel significant, and that the unpredictability of pregnancy changed their perspective when caring for infertility patients. For those who had undergone IVF, the process deepened their understanding of the logistical and emotional challenges faced by patients.

Providers consistently described keeping discussions of their own pregnancy to a minimum, prioritizing the patient’s care and maintaining professional boundaries. If providers were asked about their pregnancy, most reported using an internal script, often making a brief acknowledgment and then redirecting the conversation back to the patient. Exemplar quotes discussing the development of a script are presented in Table 2. Most noted that they wanted the focus of the visit to be on the patient and hoped to prevent patients from having a negative reaction to their pregnancy. Several noted that even when patients were congratulatory, they would answer one or two questions and then direct the discussion back to the patient. Others described downplaying their pregnancy to avoid triggering negative emotions in their patients.

Table 2.

Quotes on the physician script for addressing pregnancy with the patient.

Situation	Quotes about “script” used or advice
Developing a “script”	I think just being aware of how (disclosure) might impact your patients either positively or negatively, knowing that patients may ask you questions and thinking about how you would respond or how much you want to share ahead of time, because you know sometimes they do actually use intrusive questions and just being able to have your own boundaries and know what you’re willing to share ahead of time I think is important.–2108 I would encourage the conversations about that with me or other mentors … to talk through (patient disclosure). I don’t think there’s any one right way to do it, but there (are) probably very wrong ways to do it. Obviously, you could think of some extremes, but I don’t think that there’s any one right way to do it. I think encouraging having discussions and conversations around it to help everybody feel more comfortable, so it isn’t an elephant in the room in the sense of you don’t go into your first interaction with the patient and be like “oh I don’t even know how to handle it” or “how do I deal with these feelings of guilt.” Just so that it’s processed a little bit more.–2109
Addressing visible pregnancy	If it’s an in person visit and there’s visibility, I think, I honestly don’t know, I would just say, “Oh, obviously you know as you can see I’m pregnant right now and I really hope we can get, my goal, is to help you become pregnant, or grow your family, or become a parent in some way.”–2111 It wasn’t like we braced them for me walking in, or anything like that, that would be too much. It was kind of like I would walk into the room with the attending and sometimes they would say, “Oh you are pregnant too?” and we would be like, “Hopefully it’s good juju”.–2110
Responding to patient congratulations and/or questions	I would say, “I am due in [month of due date], anyway, this is the rest of the procedure, thanks for asking.” I would not dwell on it.–2111 Occasionally people would say something and most of the time it was a positive, “Oh are you pregnant” or you know like “Oh I am so happy for you” or whatever it is, and I would like to say “thank you,” and we would move on.–2104
Acknowledging patient’s emotional response(s) to pregnancy	I don’t know how to concisely say that in an introduction or during the course of an appointment, but acknowledging you know, “I am very aware of that I’m pregnant. I’m just going to address the elephant in the room and my intention is not at all to make anyone feel sad, but to get you to that that end goal. And it’s okay if you are a little bit mad or if something like that came up”.–2111
Disclosing maternity leave	If they want you to do a surgery for them, or they are expecting to do an embryo transfer and you are not going to be there for those 2 months because you’re on maternity leave, then I could see, (saying) “Well, I am going to be out for this amount of time so let’s try to figure out a different timing or a different way to get this done”.–2102 (When) I prepare my patients for my leave … (I) tell them, “I want to be really transparent, I am about ready to go out on leave, for my maternity leave, so my partners are going to take care of you”.–2103

Theme 2: Interactions with patients

Participants reported that although many patients did not acknowledge a provider’s pregnancy, those who did generally did so in a positive manner. Congratulatory remarks were common, often accompanied by questions about the due date or the baby’s sex. Several providers described patients who were warm and kind despite their own recent unsuccessful conception attempts. Positive responses were more frequent among certain patient groups, including those undergoing embryo banking or fertility preservation, same-sex female couples, and patients with living children. Patients who had living children would often ask questions, share birth dates, or discuss parenting experiences. Some providers noted that these interactions helped build rapport, occasionally allowing them to offer perspectives as both a physician and as an expectant parent.

Although the majority of providers endorsed experiencing positive (83%) and/or neutral (75%) interactions with patients while pregnant, 67% of the providers interviewed described negative interactions. These included patients being visibly upset or tearful, making disrespectful comments, and violating interpersonal boundaries. Several noted that once they were visibly pregnant, patients would frequently bring up the provider’s pregnancy in awkward or emotionally complex ways, which contributed to feelings of anxiety. One physician described feeling as though she needed to “walk on eggshells” with certain patients. Physicians described employing various strategies to disarm tension, such as a brief acknowledgement of the pregnancy, answering one or two questions, spinning their pregnancy as “good juju” for the patient, or otherwise maintaining normal conversation and rapport-building whenever possible.

Although described as relatively rare, personal boundary violations were some of the most memorable and emotionally charged experiences physicians described. Boundary violations ranged from probing personal questions to physical contact. Some patients asked the provider whether the pregnancy had required ART, or about personal decisions such as baby names or future family-building plans. Others described patients touching/requesting to touch their pregnant abdomen, framed as “good luck” to pass along “pregnancy magic.”

Occasionally, participants noted that negative interactions were not openly expressed to the physician. They would learn about them indirectly from nursing staff or office surveys. One provider recalled being told by staff that a patient was “inappropriately upset” about her pregnancy, even though nothing had been said during the actual appointment. In one extreme case, a formal complaint was filed against a visibly pregnant attending physician, accusing the clinic of insensitivity for allowing her to care for infertile patients. Physicians were often acutely aware of the emotional tension in the room, even when patients did not verbalize their feelings.

Participants were asked if they believed that a physician pregnancy should be disclosed to patients, and if so, how it should be done. No participants thought providers should proactively disclose their pregnancy. The reasoning behind nondisclosure included maintaining professionalism, keeping the visit about the patient, respecting patient autonomy (patient’s choice to discuss), normalizing physician pregnancy, and physicians’ right to privacy and nondisclosure. Others expressed uncertainty about the appropriateness of disclosure, indicating that neither bringing up the pregnancy nor ignoring it seemed appropriate.

A few physicians noted that they believed disclosure would be appropriate in certain situations, including when discussing an upcoming leave of abstinence (maternity leave), when the pregnancy might directly affect a patient’s care (i.e., surgical procedure or cycle treatment), or if the shared experience might provide reassurance to the patient in some way (Table 3). The depth of the patient-physician relationship was also mentioned as a factor in determining whether disclosure would be appropriate, with disclosure deemed more appropriate with patients the physician knew better. Some participants shared their experiences with pregnancy disclosure, whereas others felt uncomfortable with disclosure and wanted a uniform clinic-level plan to address physician pregnancy.

Table 3.

Concept map for factors impacting disclosure of physician pregnancy.

Domain	Patient centric care factors	Professional environmental factors	Physician factors	Patient interaction factors
Disclosure Nondisclosure	1) Planning for maternity leave			1) Patient initiated conversation 2) Patients with an established relationship 3) Disclosure of need for ART may encourage/benefit the patient
	1) Acknowledge that seeing a pregnant provider can be difficult for a subfertile patient	1) Mentor advice	1) Empathy for the patient 2) Self-conscious of physical manifestations of pregnancy
	1) Taking steps to decrease patient discomfort 2) Provider pregnancy not relevant to quality of patient care	1) Culture of patients first/protecting patient 2) Enforcement of culture of patients first/protecting patient by administration and/or colleagues 3) Lack of supportive resources/plan for disclosure (including related to maternity leave)	1) Physician right to nondisclosure 2) Survivor guilt 3) Physician anxiety of patient reaction to pregnancy 4) Compartmentalization of work and personal life

Note: ART = assisted reproductive technologies.

Theme 3: Clinic and professional environment

Participants described the difficulties of working with subfertile patients while experiencing their own pregnancy and discussed a lack of workplace or training support, including insensitive remarks from colleagues and insufficient support for family-building. Physicians described being asked by colleagues, partners or supervisors to wear a larger white coat or scrubs and to make changes to their clinical schedule to avoid patient interactions while pregnant. Participants expressed a desire for increased support for and normalization of pregnant physicians, noting that the desire for children is common. Other suggested options for pregnancy support and normalization included department leadership actively protecting providers’ rights to privacy and nondisclosure, and providing moral support when providers experience inappropriate comments or complaints from patients. Many providers expressed the sentiment that while physician’s pregnancy “[doesn’t need] to be paraded, it shouldn’t be hidden,” either.

Participants described dissonance in the REI field: The family-building goals, lifestyle recommendations, and timeline adaptations routinely suggested to REI patients are not uniformly encouraged and are, in fact, frequently discouraged for REI physicians in the workplace. Suggestions for a more supportive family-building culture included creating residency and fellowship programs that accommodate female physicians’ conception plans through flexible training schedules, etc. Other practical areas for improvement included improved maternity leave options and pumping facilities. Specifically, 83% of participants described a desire for an increased length of maternity leave, both during fellowship and as attendings. Taking maternity leave often incurs a steep penalty when fellows are forced to extend the length of their fellowship. Participants also cited the negative impacts and financial repercussions of taking maternity leave while in private practice.

Theme 4: Personal emotional experience

When participants were asked to reflect on their decision to pursue pregnancy and feelings experienced when they found out they were pregnant, they endorsed both challenging emotions, such as survivor guilt and anxiety, as well as positive emotions, including happiness, excitement, and relief. Protective coping strategies such as compartmentalizing work and personal life and discussing with mentors were employed to address challenging emotions.

Seventy-five percent of the participants mentioned feeling survivor guilt (psychological distress due to surviving or escaping a situation relatively unharmed or unaffected, as compared with others) because they were pregnant while their patients struggled to conceive. They described an uncomfortable blend of positive emotions about their pregnancy and negative emotions about their patients’ infertility (guilt, sadness). Some questioned the inherent unfairness of the situation and their own (albeit unintentional) role in potentially intensifying patients’ grief. These tensions were often linked to professional norms within medicine, where the expectation to “always put the patient first” made prioritizing one’s own needs and family-building goals feel uncomfortable.

Participants described multiple sources of anxiety related to their own family-building, including concerns about infertility, the health of their pregnancy, successfully balancing career demands, and the challenges of raising a child. Some participants noted that anxiety persisted during various stages of pregnancy. For example, many described an increased awareness of their own fertile window. Others expressed more specific worries about challenging patient interactions or adverse pregnancy outcomes, particularly during the early stages of pregnancy. Their clinical care experiences also influenced when and how they chose to build their families, with increased exposure to patients struggling with delayed childbearing creating a sense of urgency. Even those who conceived without difficulty made deliberate timing decisions, planning pregnancies around patient care responsibilities during fellowship or while establishing their career. Many described considering how to further career goals while parenting young children. Others spoke about their utilization of and increased access to laboratory tests or ultrasounds that fell outside the bounds of what their provider (or they themselves, as physicians) would have recommended. Once pregnant, their medical knowledge often increased their anxieties. Participants often described minor issues like spotting or abnormal test results that could immediately lead to worst-case scenario thinking. Whether the path was smooth or marked by challenges, their experiences reinforced a unifying truth: fertility is a finite window, and pregnancy with live birth is never guaranteed.

A protective coping strategy that physicians used to manage survivor guilt and anxiety was the compartmentalization of work and personal life. Physicians mentioned a desire to both build their family and to be successful at work, while noting challenges in trying to blend the two goals. Some participants described conversations with physician mentors as being a way to develop realistic plans and expectations, cope with feelings of guilt, and balance professional responsibilities with personal pregnancy plans and family needs. Conversations with mentors often included debriefing challenging patient interactions. Mentors provided reassurance that negative patient reactions to the pregnancy were not the provider’s fault and discussed ways to understand these reactions. Mentors could also help physicians develop a script to address their pregnancy if a patient brought it up. Preparations like this allowed mentees the time to process the best ways to respond as well as assess the amount of information they might share.

Discussion

Pregnancy poses unique challenges for REI physicians. Thematic analysis was conducted on the content of semistructured interviews with physicians who provided care to infertility patients while they, themselves, were pregnant. Four primary themes summarized the findings: (i) patient centeredness; (ii) interactions with patients; (iii) clinic and professional environment; and (iv) personal emotional experience. The personal accounts associated with these themes demonstrate the unique challenges of being pregnant while treating infertility patients. Study findings highlight the burden of balancing the personal right to build a family with a professional desire to maintain sensitivity to patients’ emotional needs.

Many of the themes identified both positive and negative aspects of the pregnant physician’s experience. Interviewees who did not personally struggle with infertility described a sense of relief. Both those who personally experienced infertility and those who did not described the experience of trying to conceive as deepening their sense of empathy for patients. Most physicians experienced positive emotions when they found out they were pregnant, even though many elected to postpone childbearing due to the demands of clinical training and practice. Many noted that increased medical literacy and access to tests and equipment were a double-edged sword: They were more informed than patients but also hyperaware of their own fertility and what could go wrong when trying to conceive. Once pregnant, some participants requested extra, nonstandard monitoring such as blood draws and early ultrasounds.

An important study finding centered on physicians’ perception of the professional culture of medicine and its impact on their pregnancies. This culture encourages the prioritization of patient care before self. Participants described a sense of professional responsibility that often trumped their personal needs, leading to feelings of anxiety, a need to compartmentalize work and personal life, and guilt about their pregnancy. In a field that is built upon family-building and optimizing patients’ access to parenthood, it is vital to support the very people who carry out this mission. When physicians’ reproductive goals are ignored or devalued, burnout and provider attrition are more likely.

The ways in which patient-provider interactions changed because of the provider’s pregnancy were frequently discussed. Participants described hiding their pregnancy (e.g., by wearing larger scrubs or a white coat or rearranging clinical schedules) to prevent patients from experiencing negative reactions. Participants noted that they would not bring up the topic of their pregnancy unless it was to discuss an upcoming maternity leave or other direct impact on patient care, leaving the decision to discuss the pregnancy to patients. This finding aligns with the dynamic tensions described by Klitzman as contributing to infertility patients’ perceptions of gaps in communication and relationships with their REI. Several participants sought guidance from mentors or clinic personnel on ways to discuss the subject of their pregnancy, whether proactively or in response to patient queries, noting that input and support tended to be sparse.

Guidance on pregnancy disclosure or setting patient expectations for encountering pregnant staff will be valuable for clinics, as well as for medical education and training purposes. Subfertile patients have been noted to highly value provider communication and relationship yet are frequently disappointed by the quality of both with their REI (13). Casual comments can contribute to patients’ dissatisfaction with care (14), in situations where they are not triggered by encountering a visibly pregnant person. The investigators of a 2021 qualitative study examining female patients’ experiences related to discontinuation of ART noted that “fertility treatment continues to be a disempowering experience for women.” They go on to highlight the importance of patient-centered approaches , which emphasize autonomy and empathy when discussing difficult topics in fertility care (15). A 2021 case study examined ways that a mental health care provider’s pregnancy impacted their treatment of an oncology patient facing fertility loss (16). The investigator concluded that disclosing before showing physical signs of pregnancy is a way to prioritize patient consent and autonomy and allows the patient to choose whether to continue the patient-provider relationship. It was suggested that the pregnant provider should also consult with colleagues so that they can process patient feelings as well as their own. Numerous studies have examined difficult patient-provider conversations, especially in relation to cancer care (17, 18). Provider fears that may impact these difficult discussions include fear of being blamed for bad news, fear of the unknown/untaught, fear of expressing emotions to the patient, and fear of patient reactions (19). Suggestions for providers center on demonstrating empathy by listening, using silence, and giving the patient an opportunity to reflect on their own feelings.

Further study of patients’ experiences when working with a pregnant REI will provide vital and specific information for the field of fertility care. Patient preferences for disclosure will need to be balanced with respect for provider rights to privacy and nondisclosure of their health information, along with equal opportunity laws established by the Pregnancy Discrimination Act of 1978 (20) to establish best practices to appropriately and compassionately address the issue to maintain rapport and trust in the physician-patient relationship while REI physicians work to achieve their family building goals.

Strengths and limitations

This study contributes highly unique and important findings to the literature. To our knowledge, this is the first qualitative study to explore pregnant physicians’ experiences while caring for infertility patients. This study offers valuable insights into patient-physician interactions, needs, and expectations. These insights not only validate the experiences of those who have already followed this path but also offer support and guidance to physicians who are planning for pregnancy or are currently pregnant while providing infertility care. This study also highlights female REI physicians’ wishes for improvements in the field, including improved maternity leave and a more generally supportive family-building medical culture. Ultimately, attention to the needs of REI physicians will benefit fertility clinic patients, as well.

This study is not without limitations. We interviewed a small group of individuals recruited from the SREI and social media websites which likely impacts the generalizability of results. A larger study sample size with broader recruitment methods could provide more generalizable findings. Qualitative research is also often impacted by the subjective interpretations and biases of the researchers, which can subsequently shift study findings and cause challenges for replicability. A great deal of time was spent in this study, however, ensuring interrater reliability and strong agreement on thematic elements and coding. Ultimately, we believe that the advantages of qualitative design—rich, detailed information exploring the complex emotions, experiences, and values of participants—can contribute important, unique data to the field and inform subsequent quantitative studies.

Conclusion

To our knowledge, this study is the first in the field to qualitatively assess pregnant reproductive endocrinologists’ experiences and perceptions while providing fertility care. It highlights the challenges of providing patient-centric fertility care while attending to one’s own family-building goals. Participants noted the difficulties that can arise when these goals are seemingly at odds. A call for improvements in the REI field was also made, with participants desiring better, more consistent support related to maternity leave, collegial collaboration, and guidance for managing challenging patient interactions. We hope that the longer-range impact of this study will be not only a better understanding of pregnant providers’ needs and the development of more targeted, universal patient-care protocols but also improved support, empathy, and clinical care for REI patients.

CRediT Authorship Contribution Statement

Emily Capper: Writing – original draft, Supervision, Project administration, Conceptualization. Stacey A. Pawlak: Writing – review & editing, Supervision, Project administration, Investigation, Conceptualization. Karen M. Summers: Writing – review & editing, Investigation, Data curation, Conceptualization. Rachel M. Whynott: Writing – review & editing, Visualization, Supervision, Data curation, Conceptualization.

Declaration of Interests

E.C. has nothing to disclose. S.A.P. has nothing to disclose. K.M.S. has nothing to disclose. R.M.W. has nothing to disclose.