By Scott J. Schweikart*
Many medical professionals in the United States today face a personal dilemma over whether to delay (and potentially forego) starting a family in order to fulfill lengthy medical training. In response to these concerns, the American Medical Association (AMA) recently passed a new policy that supports trainee access to assisted reproductive technologies (ART).
Issues around reproduction and fertility preservation are especially acute for female physicians, who complete their medical training at an age of 31.6 years. For some specialties, like surgery, which require more lengthy training, the average age of completion is 36.8. These lengthy trainings coincide with prime reproductive years, as women face substantial decreases in fertility by their late thirties. As a consequence, female physicians have an infertility rate twice that than the general public, at 24.1%, compared to the general public’s 10.9%.
Compounding the problem is the expense of assisted reproductive technologies, such as in-vitro fertilization and oocyte cryopreservation. In the U.S., the cost of one cycle of in-vitro fertilization averages at $23,474, and, if multiple cycles are needed to achieve pregnancy, costs reaching into the six figures are not uncommon. Oocyte cryopreservation — an ART that has gained popularity in recent years and is no longer considered experimental — involves extracting a woman’s eggs and freezing them in the hopes of preserving the reproductive potential of the eggs for use in pregnancy later in life. However, this technology is expensive; it can cost $15,000 to $20,000 in the U.S.
Insurance coverage for oocyte cryopreservation usually hinges on whether the procedure is deemed elective or medically indicated. Medically indicated procedures to freeze eggs occur when a woman is undergoing a treatment that may limit fertility, such as chemotherapy. By contrast, an elective procedure is one made most often for personal reasons to preserve fertility, and not in response to a medical treatment. In the U.S., insurance coverage rarely covers the elective freezing of eggs, leaving those individuals who wish to freeze their eggs with the enormous expense. For young medical professionals, the cost of fertility treatments may be up to one-quarter of a resident’s annual income.
In May 2022, physicians from the Residents and Fellows Section (RFS) of the AMA highlighted these issues in a draft resolution calling for the AMA to support young physicians’ access to ART and fertility treatments.
At its last annual meeting in June 2022, the AMA passed RFS’ policy in support of access and insurance coverage fertility preservation and treatments for residents and fellows.
The policy states:
Our AMA: (1) encourages insurance coverage for fertility preservation and infertility treatment within health insurance benefits for residents and fellows offered through graduate medical education programs; and (2) supports the accommodation of residents and fellows who elect to pursue fertility preservation and infertility treatment, including but not limited to, the need to attend medical visits to complete the gamete preservation process and to administer medications in a time-sensitive fashion.
Dr. Danielle Rochlin, one of the sponsors of the RFS resolution, notes that the policy is a first step, explaining that “[w]e need buy-in from GME [graduate medical education] leadership at individual residencies and fellowships” and that “the next step is for those leading residency and fellowship programs to actually implement these benefits in housestaff health insurance programs.”
Having the AMA formalize this policy is useful in that it allows for those lobbying for changes to cite the AMA — as the largest and oldest physician professional organization, and an influential and informed authority — to provide weight and support behind their arguments for change. Additionally, the AMA uses its policies to strengthen its own lobbying efforts on behalf of physicians.
The new AMA policy also nicely compliments existing AMA policy on gender discrimination and gender equity. For example, AMA House Policy, “Principles for Advancing Gender Equity in Medicine” declares that the AMA “ is opposed to any exploitation and discrimination in the workplace based on personal characteristics (i.e., gender).” Additionally, the AMA Code of Medical Ethics, Opinion 9.5.5, “Gender Discrimination in Medicine,” states that:
Inequality of professional status in medicine among individuals based on gender can compromise patient care, undermine trust, and damage the working environment. Physician leaders in medical schools and medical institutions should advocate for increased leadership in medicine among individuals of underrepresented genders and equitable compensation for all physicians.
Opinion 9.5.5 then further states that “physicians should actively advocate for and develop family-friendly policies that promote fairness in the workplace” including “programs that facilitate re-entry by physicians who take time away from their careers to have a family” and “job security for physicians who are temporarily not in practice due to pregnancy or family obligations.”
As the Code of Medical Ethics reinforces, issues of gender discrimination in medicine are also issues of medical ethics, and physicians have a professional duty to advocate for policies that eliminate discrimination and promote gender equity.
The problems of fertility preservation and access to ART are significant for many young physicians in the profession today. The problem unequally affects female physicians more so than male physicians and is by its nature discriminatory and further harms gender equity in the profession. The AMA’s new policy supporting access to fertility preservation and ART, as well as providing for accommodations for residents, is one small part of helping physicians and the profession fulfill their ethical responsibility to eliminate such discrimination.
Scott J. Schweikart, JD, MBE, is a Senior Policy Analyst at the American Medical Association and the Legal Editor of the AMA Journal of Ethics.
*The views expressed are that of the author alone and do not represent that of the American Medical Association.
