From the June 16, 2023 issue of the Transformational Times - Father's Day
Journeys to Parenthood
Adina Kalet, MD, MPH
As another holiday celebrating parents approaches, Dr. Kalet shares her very personal, circuitous, and challenging journey toward parenthood. Statistics suggest the challenges she and her husband faced are shared by many other physicians …
I always assumed I would have at least two children. My husband and I wanted a family and cherish our close sibling relationships. At 32, after completing residency and fellowship, and having started my first clinical job, I got pregnant easily. The pregnancy was uneventful, even fun at times, although I eventually needed a Caesarean section after 30 hours of labor for “failure to progress.” Even though our first child had neonatal jaundice and needed to stay in the hospital for a few days, we all went home happy and healthy.
When Zachai turned two, we were eager to have a second child. After an unsuccessful year trying the usual way, we sought the advice of a reproductive endocrinologist. Except for feeling a bit insulted when he called me “elderly” (I did know that advancing age was the most common cause of infertility, but didn’t think 34 was all that old), we were eager to get going. Time was of the essence. Thus began the five most challenging years of my life.
We started with a series of increasingly invasive tests. After a few cycles of medication, I had two major surgeries and one life-threatening complication. Still no pregnancy. With each “failure,” there was a swift, pressured decision to escalate the technical interventions. Because of the remarkable scientific advances, the options of Artificial Reproductive Technologies (ART) were rapidly expanding; but success rates were poorly established and thought to be highly dependent on the skill of the physicians. Deciding which team was the best made a research project out of choosing where to get fertility care.
I was getting increasingly desperate. I had full-time clinical and teaching schedules and was raising a toddler. It never occurred to me to take either time off work for these treatments (it would not have been supported) or ask anyone in leadership for special arrangements. For one week of every cycle of in vitro fertilization (IVF), I needed to have daily intravaginal ultrasounds. This meant rising at 4 a.m., getting to the physician’s office, and then going to work. One Saturday morning, after another negative pregnancy test, I accidentally turned our car the wrong way on a busy avenue. Luckily, the other 6 a.m. drivers were alert, and I quickly turned the car around. I was exhausted and heartsick. I pulled over to the curb and cried.
Seeking more options
In that moment, I realized that while becoming pregnant again was unlikely, having a second child in our lives was not. That week, I attended the first in a series of workshops on adoption and joined a support group for people with “secondary infertility.”
A month later, in what was to be our final cycle of IVF, the physician told us that I had an “inhospitable uterine environment” (really, he said it exactly that way!) and further attempts would be futile. He said our only option of having another biological child would be gestational surrogacy.
I wasn't excited about surrogacy, but we explored it. A short while later, we had a conference call with a Surrogacy Agency in Colorado (gestational surrogacy was not legal in some states), where we discussed the procedural, legal, financial, and ethical challenges of having our embryos (which were in deep freeze in New Jersey) transferred to a wonderful Florida woman willing to carry this pregnancy as a surrogate.
Soon, though, I made a very different phone call.
A lawyer who specialized in international adoptions listened to my story carefully. She asked me nothing about body size, menstrual cycles, uterine environment, or sex life. She said nothing about lab tests, operating rooms, or anesthesia risk. She empathized with my sense of failure, sadness, and disappointment. After hearing that my husband and I had a combined age much less than 100 years, were employed and in good health, and were already raising a child, she reassured me that if we wanted another child—and were willing to complete reams of paperwork, be fingerprinted three different places, and welcome a social worker for an extensive home visit—we most likely would have a child as soon as the New Year.
Three weeks later, we received a fuzzy faxed photograph of a beautiful newborn. It was the week before the Jewish New Year (I had thought she meant January 1!). We quickly arranged a trip abroad to meet the baby, but we needed to leave her in family foster care as the slow, rigorous legal adoption process proceeded. We were receiving weekly updates about our “to be” child, preparing our now 6-year-old for life as a big brother, and anxiously awaiting “the call.”
We brought her home in January and the rest, as they say, “is history.”
Physicians have more trouble getting pregnant than the general population
One in four American physicians seek infertility treatment. The well-documented, progressive decline in fertility with aging occurs a decade earlier in women than men, making the choices and timing of childbearing for women physicians especially important to consider.
While in retrospect, most (56.8%) women physicians have no regrets regarding childbearing, 28.6% say they would have attempted pregnancy earlier, 17.1% would have chosen a different career, and 7.0% would have chosen to cryopreserve their eggs (Stentz, et. al. 2016). Available options are likely to become less invasive and more effective as the biology of ART evolves, changing the decisions people make.
Physicians who had babies during medical school and residency perceived less workplace support (68.2%) than those who had their first pregnancies following training (88.6%). Nearly half of physicians who eventually faced infertility were surprised, as I was (Stentz, et. al. 2016).
Infertility, pregnancy complications, and miscarriages are associated with high rates of burnout (Casilla-Lennon M, et. al. 2021).
Understanding of—and attitudes about—adoption and alternative ways to create a family are also rapidly evolving (more on that at another time). Involuntary childlessness is more common among physicians compared to the general population and may be preventable if we are willing to acknowledge and meaningfully address the problem. As women make up a significant proportion of all physicians, this issue impacts the health of the profession and the public.
Like all women, physicians need support during this difficult experience
In a recent article in our premier peer reviewed journal, Academic Medicine, three physicians with personal and professional experience with infertility made three relatively modest and achievable calls for change:
Increase education and awareness about fertility.
Research has shown that nonfertility specialist physicians do not truly understand how rapidly fertility declines with age and overestimate the effectiveness and underestimate the cost of fertility treatments.
Addressing these knowledge gaps and providing individualized counseling is a simple strategy to help our future colleagues make the best choices for themselves.
After nearly 40 years as a physician and 30 years as a parent, I have very few regrets about the choices I have made. I would not trade the wisdom I have gained from having faced very hard things. I would not have made different choices. But if I had known more and had a trusted mentor to turn to for help in navigating the hard times, it would have saved me a great deal of personal suffering.
Combining a medical career with parenthood is challenging! Explicit and balanced
discussion of these issues during medical education only seems right.
Provide insurance coverage for and access to fertility assessment and management.As I have discussed in my Mother’s Day Director’s Corner, insurance coverage for fertility treatments is not ubiquitous. Infertility treatments are very costly financially, physically, psychologically, and spiritually. Even with two incomes, my husband and I needed to borrow money to pay for the care we pursued.
Offer support for trainees and physicians undergoing fertility treatments.I sought group therapy and needed care for anxiety and insomnia from a psychiatrist. I asked for and received the support of my faith community. I was on my own to work all this out. As institutional leaders and educators, we have an opportunity to improve the long-term resiliency and well-being of our physician workforce through increased awareness, empathy and understanding.
We can reduce the concern many have about being stigmatized by peers and leadership for taking time away from work to attend to personal needs by making it possible to schedule fertility-related care as part of routine health maintenance.
Working with young physicians to ensure they can flourish in the profession in the long haul is fundamental to our work as medical educators. Helping others build healthy families is core to that mission.
Given that prime childbearing years overlap with the most intense decade of a physician’s education and training, our systems must be structured so that every physician parent and medical family—no matter how that is defined—can thrive.
Like many others before and since, we took a circuitous route to parenthood of our two wonderful children. I hope our story helps others talk more about these issues. As colleagues and friends—and as institution leaders—we must be mindful that becoming a family is one of the most important, frightening, and wonderful transitions life offers.
For further reading:
- Stentz NC, Griffith KA, Perkins E, Jones RD, Jagsi R. Fertility and Childbearing Among American Female Physicians. J Womens Health (Larchmt). 2016 Oct;25(10):1059-1065. doi: 10.1089/jwh.2015.5638. Epub 2016 Jun 27. PMID: 27347614.
- Marshall, Ariela L. MD; Arora, Vineet M. MD, MAPP; Salles, Arghavan MD, PhD. Physician Fertility: A Call to Action. Academic Medicine 95(5):p 679-681, May 2020. | DOI: 10.1097/ACM.0000000000003079
- Casilla-Lennon M, Hanchuk S, Zheng S, Kim DD, Press B, Nguyen JV, Grimshaw A, Leapman MS, Cavallo JA. Pregnancy in physicians: A scoping review. Am J Surg. 2022 Jan;223(1):36-46. doi: 10.1016/j.amjsurg.2021.07.011. Epub 2021 Jul 21. PMID: 34315575; PMCID: PMC8688196.
Two resources I found extraordinarily helpful in my journey:
Adina Kalet, MD, MPH, is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.
