Knocked Up, With Difficulty

In July of my general surgery chief year, I sent an angry email. It was a spur of the moment, born of frustration email that should have come with a pause button, but I’m still working on my pause button. I was frustrated with the lack of transparency in our healthcare coverage, the lack of infertility coverage for residents, and most of all, with the fact that I was infertile.

I didn’t know who to air my grievances at—the large hospital corporation that signed my paycheck? My hapless general surgery program director who had no control over my health coverage? My ovaries? I went for accessibility.

This is what my program director wrote back:

Linda,

Sorry for the frustrations. I will forward to the proper people at [hospital administration/graduate medical education] as well as to Dr. [Chairman] (if that is OK with you). To my knowledge, you are the first to try this as a resident in Surgery, and since most other residencies are much shorter, you may be one of the first in GME [graduate medical education] to try to sort through the insurance issues with this, if not the first […]

Sometimes it is good to be special. As surgical residents, we spend years neglecting ourselves and our families to receive external feedback that we are special for our achievements and performance. But this was not a good special. It was a very isolating special.

But how alone was I really? The truth is, in the US, 1 in 10 women in the general population experience infertility. The rate is much higher amongst female physicians, with 1 in 4 female doctors reporting infertility with an average age at diagnosis of 33 years. Sadly, the rate is highest amongst female surgeons. According to an article published in 2014 by Philips et al for the Journal of the American College of Surgeons, one in three female surgeons experience infertility, of which two-thirds go on to use assisted reproductive technology, such as in-vitro fertilization (IVF), to achieve pregnancy.

I didn’t know any of this when I started my journey, but in hindsight, I had to wonder: why is it that seven years after this publication was printed in one of our most prominent surgical journals, at a major training institution boasting over 50% female surgical trainees, I was being told that it was unheard of that a 33- year-old trainee was navigating IVF?

At that time in my general surgery program, there were 71 residents, 39 of whom were female. Statistically speaking, 13 of those women will experience infertility at some point if they choose to start a family through biological means. Now, most of them were blissfully not yet 33, and thoughts of fertility might be understandably distant.

But after receiving that email, it became my mission that no other female surgical trainee having to wade through infertility should feel so undesirably ‘special.’

**

These pervasive beliefs that marginalize ‘normal’ experiences of trainees, such as needing medical care to achieve pregnancy, keep the field of surgery sterile and unwelcoming of outside experiences. During that summer, I cried a lot. In the last 12 months, I had discovered that I loved cardiac surgery. When I was in those operating rooms, it felt like everything in my life had clicked into place. But I was also in love and wanted to start a family, and it wasn’t happening. As we progressively failed medicated cycles, intrauterine insemination (IUI), and moved closer to IVF, I was gripped by the thought that going through IVF would not be compatible with being a cardiac trainee. This led to a spiral of pervasive thoughts – Did I make the wrong career choice? Should I choose cardiac at all? Should I choose having a family or doing what I loved for work? Was I guilty of causing my own infertility by working, operating and taking call?

Why did I think that IVF and surgical training were not compatible? For one, I had never seen anyone do both before. Secondly, I had a poor understanding of the physical and time requirements that IVF needed, but I knew as a resident I had little control over my own schedule. And lastly, as a young person who formerly had few personal needs outside of work, I had previously been unforgiving to those who did. Now that it was my turn, I felt like I needed to apply the same stringent rules to myself.

The truth of the matter turned out to be far better than I expected. When I asked to change my schedule to a lighter rotation during the month of our IVF cycle, I was met with immediate support by my program. When I asked my cardiothoracic fellowship director if I could move my general surgery and cardiac rotations around to accommodate procedures (a luxury of being an integrated 4/3 resident), he said that he was committed to whatever I needed to take care of my family, and that fellowship would be waiting when I finished.

I was floored. I realized that the months I spent worrying about the imminent end of my career due to infertility was a false narrative I had told myself, created of ignorance and incomplete interpretations of what I saw people doing around me. I learned that we have to work hard on a personal level to explore and create truths that are better than the received wisdom, and that as organizations, we can also change the contexts that younger generations see.

When I was a fourth-year medical student, I rotated as a sub-intern with the chief of cardiothoracic surgery. I loved my time in the operating room, but I didn’t think cardiac surgery was a possible career for me. Even after years of higher-level schooling, research experience and statistics courses, the human brain, or at least my human brain, is a simple one. On service, I saw two male fellows going into cardiac, and two female fellows going into thoracic. There was one female faculty member in the division of 18. I internalized a message that no one spoke aloud to me: cardiac surgery is for boys, not girls who want to start a family.

Now, I’m grateful every day that life gave me a second chance to find my way back to cardiac surgery. After realizing my own cognitive limitations that prevented me from choosing cardiac surgery as a student and then questioning that choice again when faced with infertility as a resident, I take every chance I can to show female students and trainees that it is not either/or. I want them to learn suturing and one-handed tying, think about drainage and cannulation strategies, and only ask themselves: do I like this or do I not, with no barriers in their mind that it would not be for them, simply because they are girls.

**

I’ve been lucky in my life to have had little interaction with health insurance before all this, but this was my introduction. Before we could start IVF, we needed what was called “financial clearance” from the billing office of the reproductive endocrinology department. This turned out to be a phone call where they looked through my insurance coverage and immediately cleared us. In return, I got little clarity for myself.

They told me that my insurance coverage through my hospital employer included a $7,500 lifetime benefit for fertility treatment, and a $2,500 lifetime benefit for fertility medications. Was this a good amount of coverage? I had no idea. I learned that a lifetime benefit means that once you use it, it doesn’t start over the next year. It also means that “out of pocket max” does not apply. Once the insurance has completed $7,500 in payments, they would not pay any more. The financial office asked us if we wanted to use the insurance benefit. I was confused by this question. Why wouldn’t we? It’s like free money. Except it isn’t free, because I pay the premiums out of my biweekly paycheck for each 160 hours worked. I asked them what a round of IVF costs in total. This seemed like a reasonable thing to want to know. They told me there was no way to tell us this. What they could tell me was, without insurance, an out-of-pocket round with no frills (intracytoplasmic sperm injection, genetic testing of embryos for example, which would be extra), was $15,000, not including medications.

I thought ‘Ok, $15,000, we have a $7,500 benefit, so … we should plan on owing $7,500.’ Basically, I was covered for half the round. The lady told me, ‘Oh no, it doesn’t work like that, if you use insurance, we bill the insurance a different total amount.’ I told her that I have the insurance that the people who work at this very hospital gets. Can you tell me how much will be billed for my cycle then? She said this was unknowable. So, what we would owe out of pocket remained a mystery.

My husband and I had two choices. Proceed without insurance, as if I was unemployed and uninsured, or with my hospital insurance, as if I was a surgery resident who had been training at this very hospital for the last seven of my most fertile years. At that point in time, only Option 2 seemed reasonable to us.

After one failed round of IVF, this is where we stood with Option 2: $83,957.25 was billed to insurance, of which $29,214.61 was deemed to be our responsibility, along with the grief of no baby.

It was around that time that I sent that angry email.

I felt like I had worked hard, I had paid my insurance premiums, and this so-called coverage was a cruel joke that added insult to our heartbreak. After our first failed round of IVF, I was fortunate to be able to switch onto my husband’s insurance, which treated women’s health issues as human health issues, and provided complete coverage for fertility services. With this coverage we were able to complete a second round of IVF, which resulted in the birth of our rainbow daughter, Nora.

Nora as an embryo

**

After my message had been forwarded to the higher-ups, a response was forwarded back to me. This was an anonymized comment from a high-ranking female faculty member. She shares that she also did IVF, that it cost her $50k, and asks if I had considered taking out a personal loan to do this:

“I feel for the resident.  Background:  I had to go the route of IVF myself.  That was before there was any insurance coverage through [major university] for it.  But it was the best $50,000 I ever spent. However, I recognize that an expense like that is a big stretch for a resident.  I know that back in the day when I went to [local IVF clinic at major university] they told me about a company that extended credit for fertility treatments with a reasonably low interest rate. Not sure if the resident has been given that option.”

This made me realize: things are improving, because we’re having this conversation. But we’re not there yet. Though half the trainees in our general surgery program are women, does that mean we truly support women? Though we have Instagram posts showcasing the women who made it ‘all the way,’ to chief, chair or full professor, have we accounted for the era of strife misogyny through which they trained to arrive there? Does the success of women today prove that the system supports women, or is their success proof of how they prevailed despite the challenges placed before them?

To me, the proof is not in the Instagram post showcasing beaming female professors standing before a neatly manicured bed of flowers. It’s on page 109 of the organization’s health insurance policy, in the small print. It’s evidence of whether the leadership selecting coverage sees women’s issues as human issues, or whether the suggestion from the brass to a young woman struggling with infertility is to take out a personal line of credit for $50,000, at a reasonably low interest rate, in order to treat her medical condition and continue working.

We talk about the leaky pipeline, and it turns out I almost washed myself out of that pipeline because I thought I couldn’t keep training in cardiac surgery and grow my family at the same time. I’m lucky that didn’t turn out to be true. At the end of the day, I was fortunate to be buoyed by the blessings that kept me in that pipeline: my co-residents who provided me coverage when I went for ultrasounds and procedures, my incredible husband who gave me an intramuscular shot followed by a bowl of ice cream every night for 12 weeks, my program that accommodated last minute schedule changes based on how (un)cooperative my ovaries were with medication.

Today, my husband and I are fortunate to be parents to our miracle daughter, who is worth every penny and tear spent to arrive here. There are many others for whom the struggle of growing a family far exceeds what we experienced, for whom the destination of their journey ended somewhere very different than planned or remains unknown to them now. These stories within surgery need to be told. My hope is that by sharing our unique story, young women in a similar position will not have to experience the fear and panic I did, nor the financial burden, should they find themselves in a similar crossroads.

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Dr. Linda Schulte is a cardiac surgery fellow who wants to inspire change in the makeup of surgery.

The opinions expressed in the article are not affiliated with any institution, company or product. The article should not be interpreted as medical advice.

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