INTRODUCTION
Background
Given the demands of medical education and training, physicians may experience additional challenges with respect to family planning and fertility. Woman physicians are more likely to delay having their first child; one study found that the median female physician age during first childbirth was 32 years compared to 27 years in nonphysicians.[1] Age-related fertility issues can potentially have effects on students and trainees who delay having children in favor of their medical career. Stentz et al. found that among female physicians surveyed having experienced infertility, 28.6% reported they would have attempted conception earlier.[2] The current epidemic of physician burnout, depression, and distress has been well-documented.[3,4] These trends raise concerning questions about possible linkages between female physicians’ family-building attempts and disappointments and their mental health challenges.
The Present Study
Though female physicians self-report higher rates of infertility compared to the general population, there have been few interventions to address this issue.[2] Implementation of formal fertility education within medical curricula to increase awareness, including topics related to physician infertility, has been offered as a potential means to address infertility trends among physicians.[5,6] Evidence suggests that medical trainees’ knowledge on fertility and fertility-related topics is limited.[7] These deficits may be in part associated with less emphasis of fertility-related content on the United States Medical Licensing Examination (USMLE), a series of three exams over the course of an individual’s medical training required for licensure. Though intended to verify students’ comprehension of basic science topics, USMLE Step 1 scores have historically been a key factor in determining residency placement and is typically taken at the completion of the preclinical curriculum. As such, many undergraduate medical students tailor their learning to topics more likely to be seen on the examination.
Additionally, women in medicine may be particularly pessimistic as it relates to fertility; evidence suggests that female physicians underestimate their ability to conceive, especially when earlier in their career.[2] However, even a single educational intervention can significantly improve understanding of fertility decline and preservation in medical students and physicians in all levels of training.[7] The Association of Professors of Gynecology and Obstetrics (APGO) published medical student educational objectives, most recently in 2019, that included seven objectives surrounding knowledge about infertility, supported by online teaching cases, videos and self-test questions.[8] Fertility education is only one component that impacts decisions related to childbearing. Desire to have children, impact on work and career, emotional readiness, and institutional support can affect medical student and physician decisions in regard to having children.[2,9,10]
The present study was designed to assess knowledge and attitudes of medical students as it relates to fertility, fertility care, and formal integration of fertility content into the medical curriculum.
MATERIALS AND METHODS
This survey-based study was reviewed as an exempt study by the Institutional Review Boards at Indiana University (IRB 12402) and Purdue University (IRB-2022–63). The survey was administered to a convenience sample of volunteer participants recruited from the medical school classes of 2022–2025 over the age of 18 at a large, Midwest medical school. Age and student status constituted the sole inclusion criteria. The study was advertised in course websites, school student newsletter, and postings to student social media groups. The survey was delivered using Qualtrics software, Version August-October 2021 (Qualtrics, Provo, UT). Survey questions can be reviewed in https://links.lww.com/EHPF/A6.
The survey was designed based on studies from existing medical literature to evaluate aspects of knowledge, attitudes, and behaviors related to fertility and gather demographic information.[7,11,12] The survey does not represent a published, validated instrument.
Data was collected over a two-month period, allowing sufficient time for students from all class years to complete the survey. At the study conclusion, only surveys with completed knowledge sections were retained for analysis. This decision was made on the basis that the knowledge questions were the first section and to be used for description of overall medical student factual knowledge about fertility. Descriptive statistics were obtained for all variables. Mann-Whitney U tests were used to compare Likert-based data between female and male respondents. Analysis was performed utilizing IBM SPSS Statistics 28 software (IBM Corp., Armonk, N.Y., USA) with α=0.05.
RESULTS
Demographics
The institution’s medical student enrollment at the time of the survey was 1436 students.[13] Female and white students represent 47% and 72.2%, respectively, of the medical school student body. Two hundred and fifty-two students completed any part of the survey for an overall response rate of 17.5%. A total of 184 survey responses were retained for the present analysis. The survey offered the opportunity for respondents to answer or to skip any question, and some questions provided the option for multiple answers. Of those respondents who completed the knowledge section, 73.9% identified as female and 72.3% identified as white. Ninety-five percent of participants were 30 years old or younger. Further demographic makeup of respondents is shown in [Table 1].
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Table 1: Demographics of medical student respondents
Knowledge
The average score on the knowledge portion was 9.10 out of 13 possible points (70% correct). Of the 184 respondents who completed the knowledge section, 157 students identified their level of training. The mean scores out of 13 possible points were 8.5 (95% CI 7.82–9.18) for first year medical students, 9.06 (95% CI 8.72–9.40) for second years, 9.40 (95% CI 8.81–9.99) for third years, and 9.58 (95% CI 9.00–10.16) for fourth years [Figure 1]. Although scores increased each year, there was no statistically significant difference between the class years.
Figure 1: Mean Scores by Class Year. Graph of scores by class with 95% confidence intervals for average questions correct out of thirteen knowledge questions. “MS#” indicates the medical student year in training{Data: The mean scores out of 13 possible pointsMS1: 8.5 (95% CI 7.82–9.18)MS2: 9.06 (95% CI 8.72–9.40)MS3: 9.40 (95% CI 8.81–9.99MS4: 9.58 (95% CI 9.00–10.16)}
The lowest scoring questions were “at what age does female fertility markedly decline?” (42% answered correctly), “what is the chance of spontaneous conception each month before female fertility decline?” (38% answered correctly), and “what is the percent chance of success with 1 cycle of in-vitro fertilization (IVF)?” (40% answered correctly). Notably, 70% of total respondents correctly identified that physicians experience a higher rate of infertility than the general population.
Attitudes toward family building
The percentages quoted indicate percentages of respondents agreeing or strongly agreeing with the question. Respondents expressed strong interest in family building, with 76% of respondents indicating interest in having (more) biological children. This response was consistent between male and female respondents.
While interest in family building was strong, 58% of respondents had delayed or planned to delay family building due to medical education or training (64% of women and 41% of men). Of note, seventy-one percent of respondents agreed that they worried about having a child during medical education and training (77% of women and 56% of men, difference between genders significant P < 0.05). Fifty-three percent agreed that specialty choice would be dependent on family building goals (55% of women and 51% of men).
Despite the young age of the respondents, they expressed concern about fertility. The average age of respondents was 24.9 years, yet 34% of respondents worried about their or their partner’s fertility (39% of women and 21% of men). Respondents’ attitudes toward family building strategies other than biological children were briefly and incompletely explored. If affected by infertility, 6% of respondents would prefer to stay childless, and 76% expressed interest in adoption (69% of men and 79% of women).
General questions about family building strategies outside of a scenario of infertility revealed that 37% expressed interest in adoption outside of infertility (23% of men and 42% of women), while 22% would be comfortable using donated eggs, sperm, or embryos (26% of men and 21% of women). Fourteen percent of respondents felt uncomfortable with cryopreservation of embryos (consistent across genders). No significant difference in family building strategy preferences were noted related to factors such as childhood geographic location and religious affiliation.
A minority of respondents felt supported by their institution to meet needs surrounding family building (14% total - 10% of women and 23% of men).
When asked in free response format what possible beneficial effects of delaying childbearing, over half of respondents (110 respondents, 54%), cited improved financial preparedness. Other commonly mentioned benefits included increased maturity, more time for self before the responsibility of parenthood, better relationship with partner, and being at a better point in one’s professional career. Further details on respondent perspectives can be found in [Table 2].
Table 2: Respondent perspectives on fertility
Attitudes toward fertility knowledge and fertility medical education
Respondents indicated challenges to their current knowledge base and counseling skills regarding fertility. Less than half of the respondents rated themselves as knowledgeable about male and female factors contributing to infertility (42% overall - 45% of women and 31% of men) and with options for individuals struggling with infertility (31% overall - 32% of women and 26% of men). Thirty-eight percent expressed comfort explaining fertility to patients (54% of men and 34% of women). Respondents indicated they valued medical school course content on fertility and did not attach the value of this content to its representation on USMLE Step 1. Eighty-nine percent indicated interest in learning about lifestyle or other factors to improve fertility, and 76% regarded learning about challenges to physician infertility as important.
Respondents agreed that physicians should be knowledgeable about fertility to guide patient care in all specialties (90% overall - 92% of women and 82% of men).
DISCUSSION
The trend of increasing medical student knowledge across the four years of medical school was not statistically significant, signaling a persistent knowledge deficit. The lowest scoring questions surrounded age of marked fertility decline, rate of spontaneous conception, and chance of success with one round of IVF. A majority of students were able to correctly identify that physicians experience higher rates of infertility than the general population. Although examining different populations compared to existing research (medical students vs. residents and house staff), our study similarly suggests fertility knowledge is limited among participants, though interest and recognition of its importance is present.[7,12] Other studies have suggested fertility-related knowledge gaps in all years of medical training, potentially reflecting inadequate coverage of fertility in medical school.[14,15,16,17] Lack of knowledge about fertility and conception trends with age, along with delayed onset of childbearing into life phases associated with declining fertility, could contribute to higher rates of female physician infertility.[1,18]
Medical students are interested in having biological children and building their families, but medical school and training impact family building and planning. Over half of students reported plans to delay having children specifically due to the demands of medical training. The majority of women worry about having children during medical training; this finding is notably statistically significantly different from men, around half of whom worry about this. These concerns about the negative impacts of medical training on family building are well-founded. A survey of participants at a women physicians’ leadership conference revealed that 25% of respondents reported fertility issues and indicated that the demands and work hours of medical training contributed to delayed childbearing.[9] These findings are consistent with studies demonstrating later childbearing among female surgeons compared to male surgeons and their non-surgeon partners and impaired fecundity in female emergency medicine physicians compared to the general population, associated with night shifts and higher clinical workloads.[19,20] These differences could indicate an increased burden on women perceiving a need to complete medical training before having children. For women who choose career paths requiring long training, such as surgical fields and medical and surgical subspecialties, program completion occurs in the third decade, when fertility typically decreases. For women taking a non-traditional route to medicine, the age at training completion is even higher. The childbearing concerns expressed by medical students early in their career are especially poignant in view of the finding that first-time parents over age 40 identified that in retrospect the optimal age for first-time parenting was ten years earlier than they had conceived.[21]
Many students also indicated that their choice of specialty is affected by their personal family goals, some forgoing specialties of interest to them because of stereotypes or otherwise perceived lack of work-life balance, a finding in-line with retrospective regrets of choice of specialty for the impact on family building expressed by female physicians.[2] Female physicians in procedural specialties have been reported to be more likely to delay pregnancy, although rates of use of assistive reproductive technology and missed work due to preterm labor and pregnancy were similar to nonprocedural specialties.[22] A 2017 survey of obstetrics/gynecology residents revealed that the majority of female respondents delayed childbearing despite their advancing maternal age, and perceived little or no support for family building from their residency programs.[23] While some medical residency training programs are in early stages of considering how their work culture may negatively impact their ability to attract medical residents, much room for improvement still exists.[24]
Concerns about the negative impacts of medical education and training on childbearing correlate with respondents’ low confidence in institutional support for family building. Only 14% of respondents report perceived institutional support for family building endeavors, leaving 86% of respondents with concerns about potential negative impacts of family building on their progress through medical education and training. These findings mirror experiences uncovered in other studies of negative perceptions of veterinary medical students about their educational institutions’ attitudes.[10,25,26] A survey of residency program directors found that while many lacked awareness about the family building goals of their residents, most believed that increasing support was important.[27] Raising awareness about fertility concerns among all members of medical training programs could be a first step toward instituting positive changes supporting family building. Given the differences in survey completion in men compared to women, this may further highlight the need to promote allyship and public support among those who might not be directly affected by fertility issues.
Many respondents have fertility and family-building options on their mind as they go through medical training, with one third noting they worry about their own/their partners’ fertility. In terms of treatments for infertility, an overwhelming number of participants felt comfortable using cryopreservation. Exploring other means of childbearing, should they or their partners experience infertility, a large majority had interest in adoption to build their families. Only 6% responded preferring to stay childless, indicating that many would consider going through fertility treatments or adopting to achieve their family goals. Researchers have investigated perceptions about adoption and assisted reproductive technology (ART) and the effects ART availability may have on childbearing age. Bell interviewed infertile individuals in the United States and determined that adoption was considered secondary to ART among respondents.[28] Kim found an association between ART availability and later socially-perceived maternal childbearing deadlines in the European Union, with younger respondents significantly more generous with maternal childbearing age deadlines.[29] The authors posited that ART availability may skew perceptions about the ease of childbearing at later maternal ages. Information about the natural history of human fertility, and the costs, benefits, risks, and effectiveness of various approaches to family building could assist medical trainees in more educated decision-making.
Medical students identified gaps in their ability to counsel on fertility along with knowledge deficits. Less than half of respondents felt comfortable explaining medical aspects of fertility or infertility, understanding their options should they experience infertility, and talking to patients about fertility. In addition, nearly all respondents identified the value of and endorsed a desire to add fertility content to the preclinical curriculum – a sentiment that echoes Marshall et al.’s call to action.[6] This attitude endured despite acknowledging the limited evaluation of fertility knowledge on USMLE Step 1. This finding could be because many students follow a self-directed curriculum to study for USMLE exams and do not derive all study resources from institution-affiliated content and the recent transition of Step 1 to pass/fail.[30] Eighty-nine percent of respondents were interested in learning about aspects of fertility they could control, such as lifestyle factors. Many respondents believed that knowledge of fertility could be useful to guide patient care across specialties. Few educational modules have been described in the medical literature supporting medical education about fertility and infertility. A search of the American Association of Medical College’s MedEdPortal, a repository of medical curriculum, revealed only three modules directed toward these topics. Jin reported cases introducing preclinical medical students to principles of reproductive endocrinology and genetics in gender-diverse individuals, Chuang depicted a team-based learning exercise for third-year medical students, and Houmard described reproductive endocrinology and infertility cases aimed at medical students and residents.[31,32,33] These few examples indicate an opportunity for the development and testing of fertility-related curricular materials aimed at preclinical students’ knowledge bases that could affect both their personal and professional lives.
Limitations
The study was limited by the low response rate. Females, white respondents, and second-year learners were overrepresented compared to the population of the institution’s medical students. Overrepresentation of female respondents to other large-scale voluntary survey projects has been documented.[34,35] This study was also influenced by convenience sampling due to its voluntary nature, likely drawing more participation from students with interest in the subject. However, given this assumption is true, the knowledge is likely overestimated in this study and further investigations are paramount. Despite being voluntary and a subjectively long survey response form, the high absolute number of responses offered useful insights. Our study reflects results similar to those previously seen in the literature assessing residents and house staff in that fertility knowledge was limited among participants, though interest and recognition of its importance were present.[7,12] Our decision to analyze only surveys with completed knowledge sections for the present analysis also presents a limitation. While this procedure served the goal of analyzing relationships between knowledge and attitudes about fertility and medical education, the exclusion of 68 surveys limits interpretation to only the subpopulation represented by those who responded to knowledge questions. Further limiting this study is the use of a single university site for survey administration.
CONCLUSIONS AND IMPLICATIONS
In our study, knowledge regarding fertility among medical students did not increase throughout their 4 years, perhaps due current medical curriculum content and emphasis. These factors indicating lack of knowledge regarding fertility could contribute to increased rates of infertility in physicians. Students were also uncomfortable discussing fertility due to gaps in knowledge. Respondents noted concern with fertility, but also reservations about having children during medical training, especially among female students. Some of this hesitance likely stems from a perception of poor institutional support for family building during training. Students do have a marked interest in learning more about fertility, despite the topic’s lack of representation on high-stakes medical licensing exams. These findings strengthen the tenet of Marshal et al. that more in depth education regarding fertility in medical school would be beneficial to future physicians.
Future directions include additional research and institutional action. Obtaining detailed qualitative data would provide further insight into medical student knowledge and interest in fertility preservation. These studies would allow institutions to better understand ways to support trainees at the interface of their professional and personal lives, perhaps contributing to further improvement of female physician, resident, and student mental health. Providing health insurance coverage for fertility preservation and infertility treatment and ensuring access to these services as a standard of care could improve outcomes across the population including women medical trainees. Informal panels of female physicians, including some having experienced infertility, could also prove useful in helping students further investigate personal and social factors relating to family planning decisions, with the overall goal of increasing student knowledge about fertility. Piloting educational modules to determine the best implementation strategy for fertility content in preclinical years is the next step to increasing knowledge among medical students.
Financial support and sponsorship
The authors did not receive funds, grants, or other support for the submitted work.
Conflicts of interest
Claire Marks, Priyanka Prasad, and Dr. Julianne Stout report no conflict of interest.
Author criteria for inclusion
Claire Marks made major contributions to the concept, design, literature search, manuscript preparation, and manuscript editing and review aspects of this article. She is the guarantor of the integrity of the work as a whole from inception to published article. Priyanka Prasad made major contributions to the concept, design, literature search, manuscript preparation, and manuscript editing and review aspects of this article. Julianne Stout made major contributions to the concept, design, literature search, manuscript preparation, and manuscript editing and review aspects of this article. All authors read and approved the final manuscript.
Acknowledgements
None.
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