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SURGICAL PERSPECTIVES

Freezing the Future

Baiu, Ioana MD, MPH

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doi: 10.1097/SLA.0000000000005397
  • Free

The sharp cold needle glowed in the dark call room. My bruised-up abdomen was running out of space. A deep breath and the chilled metal swiftly and without hesitation penetrated the flesh. The medication infiltrated seemingly too slowly, and, with every painful stinging drop, I pinched my skin harder to distract my peripheral nerves. The small alcohol pad unsatisfyingly massaged my abdomen as a round drop of blood stood witness. Next injection.

The road to becoming a surgeon was never intended to be smooth, but as every optimistic idealistic medical student, I thought I could do it all. As my time, body, and mind became consumed by medicine, life took some unexpected turns. The family I had envisioned starting was not going to materialize anytime soon given the demands of the training. While my friends were posting photos of their children's first day of school, I was still counting the days left of residency. My social biology was decidedly out of sync with human biology. Meanwhile, egg freezing seemed not only a cold and bitter means of achieving a pregnancy in the future, but also unattainable as a resident. Perhaps medical school acceptance letters should now include a free treatment cycle, as the inevitable future of so many female physicians has become almost too easy to predict.

As advocacy efforts related to choosing how and when to start a family have intensified, oocyte cryopreservation has increased in popularity. In 2018, 13,275 women in the US froze their eggs, compared to only 475 in 2009.1 Nevertheless, insurance companies seldomly provide any support for what can be an exceptionally costly intervention. Most women require more than 1 cycle to attain a sufficient number of mature eggs, with each treatment costing between $15,000 and $20,000. That is a third of my resident salary simply to save the option of potentially starting a family at a later date if I cannot do so naturally.

“Dr. W., can you please close with the junior resident so that I can scrub out and give myself a shot?…” The timing matters. The temperature of the medication matters. But when your body becomes a pin cushion, embarrassment no longer seems to matter. Being open about the process with my friends, co-residents, and attendings, whether male or female, paradoxically empowered me as I felt in control of my body and decisions – a surgeon's attitude. As I admitted to my team on rounds that I was bruised and sore, more and more women and men started to inquire about the treatment, and several of them bashfully confessed to having gone through the process themselves. Many had friends who had done it, and some expressed regret at not having had the opportunity to do it until it was too late. My attendings were incredibly supportive. How could they not be?! Unbeknownst to them, the entire system had been an accomplice in getting me to this point in life, for better or for worse. Still, my partner at the time was not as enthusiastic about this “less than feminine” approach to discussing family.

A third of women surgeons report infertility, compared to only 10% in the general population.2 Whether it is the physical or the emotional toll that being a surgeon takes on our bodies, or the age at which we finish training and attain financial stability, the evidence is indisputable that physicians and, in particular surgeons, are disproportionately affected. Yet, shedding light on this process inevitably portrays women in an uncomfortable predicament. As the stigma associated with infertility remains pervasive, women choose to undergo a lengthy and painful process alone, all while balancing the most challenging and demanding of careers. Being open and honest about it ought to normalize the process, eliminate the loneliness, and provide the support from those around us and the system as a whole.

Aside from the injections, the side effects of the treatment are mostly physical (discomfort, bloating, weight gain), fortunately without emotional lability. Two weeks of carefully calculated doses and timed shots, anxiously and precisely mixing micrograms of various medications on the kitchen counter, several sharps containers, and tens of thousands of dollars invested, should, with some luck, culminate in a successful harvest. But there are no guarantees. The surgeons who underwent this process while doing 28-hour shifts, operating on their feet for 12 hours at a time without food or water, while not missing a single day of work, had variable success. The stress, lack of sleep, and inability to adhere to the strict schedule, have all been associated with decreased fertility and likely contributed to inadequate results for some.2 As a trained surgeon and keenly aware of the demands of the profession, my doctor carefully planned the treatment, day by day, hour by hour, so that the harvest would fall on a day off. Physiology is predictable and my body listened. Waking up at 3 AM, precisely 36 hours before the retrieval, to give the final injections, I felt the end in sight. The next day, as the cool fentanyl warmed up my veins, I finally relaxed.

The following 2 weeks, however, were anything but a break. Large amount of ascites quickly materialized and transformed my formerly flat abdominal wall into that of a woman during her second trimester of pregnancy. The drive to work became uncomfortably torturous and every bump in the road made me guard. Waddling my way through the operating room, I wore loose scrubs and hoped that nobody would notice the frown of a cramp. The most dramatic of these symptoms, however, was my breathing. It was unambiguously apparent that I was dyspneic and could not link more than 3 words at a time. Despite a successful treatment, my body revenged from the hormonal ovarian hyperstimulation. Although a rare syndrome, it has the potential to become life-threatening in its more severe forms. What had originally started as an empowering act, now felt defeating.

It is within our blood as surgeons to push ourselves beyond the limits of human capacity. The stubbornness to persevere despite being unable to breathe or walk was nonnegotiable. Although my friends delivered aspirin, flowers, and food to my house at night, my patients and my team were shielded from any hints of weakness during the day. Was this not being tough? Was it not a sign of strength? Or was it fear? Despite the openness that I fostered during the treatment, it became apparent that our medical culture is not yet ready to accept taking a step back to care for ourselves and our health. The hesitation I felt in acknowledging my symptoms was real and pervasive. For years, I tried to prove that I am not a woman surgeon, but a surgeon. The daily effort we place in hiding gender differences that inevitably impact our day-to-day practice is not trivial. The idea of freezing follicles forcefully places gender into the uncomfortable spotlight. Although there is a movement towards celebrating rather than suppressing these differences, my uneasiness to concede that I was ill and needed rest is proof that we are still far from acceptance.

Certainly, it is possible that our medical community is starting to listen, and it may be up to us, women, to muster the courage to talk and expose ourselves in a vulnerable light. Perhaps undergoing such an intense treatment while working as a full-time surgeon should be celebrated as an incredible feat of strength. Perhaps we need to train future generations that it is ok to stop and take care of oneself once in a while. Physician wellbeing is increasingly recognized as a key component contributing to career longevity, burnout prevention, and ultimately as having a strong influence on patient outcomes. Supporting fertility preservation would certainly aid in efforts to improve physicians’ wellness among both men and women. Furthermore, policies and support in the form of financial assistance and time off would encourage a culture of acceptance. Despite this idealism, the crude reality is that medicine has not yet evolved far enough to avoid this situation in the first place. As we made medical training more inclusive and accessible, we have not yet created a robust institution that fully supports trainees through all stages of life, so that cryo-preservation can be avoided in the first place. A proactive rather than reactive approach to fertility preservation and infertility would encourage openness, counseling, and practical discussions with medical students before embarking on a strenuous career path. In Europe, where I am originally from and where many of my friends are practicing physicians, the idea of egg freezing as a means of prioritizing a medical career over family is simply unconceivable. The system has found ways to truly support men and women in their pursuit of safely starting a family while still becoming successful doctors. As of now, the physicians who undergo this process in the United States risk their life and life-savings for a promise of normalcy at later date, while prioritizing a system that will incessantly ask for more sacrifices. Nobody lightheartedly decides to undergo this process. It is emotionally and physically draining. Yet it is out of necessity, not choice, that so many do it. Has being a woman and delaying starting a family become an occupational hazard of a surgical career? If so, who should pay for it?

Writing this piece was easy, as it was visceral, raw, and real. Deciding to publish it, however, was going to expose me in an irreversible and inevitably consequential manner. Still, it seemed like a small price to pay, despite the $25,000 debt that I accumulated. My generation felt very strongly that this story needs to be shared, but many suggested doing so anonymously, just further proof of the fear that is still ubiquitous. Shedding light on this experience should empower other physicians to be open. What in 2021 is still taboo, in a few years will likely become a casual subject. Residency is challenging. Surgical residency is demanding. When you have touched the limit, you are pushed farther. And again. And again. Until the limits become blurred. And the cold sharp needles glowing in the dark no longer seem daunting.

REFERENCES

1. Society for Assisted Reproductive Technology. Available at: https://www.sar-t.org. Accessed September 25, 2021.
2. Rangel EL, Castillo-Angeles M, Easter SR, et al. Incidence of infertility and pregnancy complications in US female surgeons. JAMA Surg 2021; 156:905–915.
Keywords:

infertility; surgeons; women physicians

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