The right time for a pregnancy

PHILADELPHIA – Through surgical masks, while retracting a portion of bowel, was not how I had envisioned having an intimate discussion about my fertility. Yet there I was, two years into medical school, in the middle of an open cholecystectomy, discussing with my attending surgeon my efforts to conceive. “So,” she said, “a pregnant medical student. That’s not the worst idea.” Soon after starting school, my periods had stopped. Further evaluation led to a diagnosis of hypothalamic amenorrhea, a form of infertility in which insufficient hormones for ovulation are produced. I suppose it’s human nature to want what you can’t have. I had always thought of having children, but years down the road, maybe in my 30s and with an established career. At that time I was 27, and going to school more than 300 miles away from my husband. Starting a family was not at the top of my mind.

But our physicians told us that our best chance of conceiving was immediately, when my age was our greatest asset. And so began our year of hormone injections, transvaginal ultrasounds and intrauterine insemination. After one of my professors, who quite accidentally became one of my reproductive endocrinologists, examined me in stirrups for the first time, I blushed before saying, “You must think I’m insane to be doing this now.” His response surprised me: “No, actually, I think you’re smart.” But as I sprinted from the exam room to an 8 a.m. discussion on kidney disease, his assurance did not prevent me from thinking that I might be out of my mind.

Still, we were over-the-moon happy when we conceived without having to move forward with in vitro fertilization, a considerably more invasive and expensive procedure. And we continued to count our blessings when the pregnancy progressed normally, without evidence of ectopic or multiple pregnancies, which are more common with fertility treatment.

I hadn’t intended to disclose my pregnancy that day in surgery. But as I was scrubbing in, the nurse asked casually, “We’re using fluoroscopy in this case, so there’s no chance you’re pregnant, right?” Fluoroscopy is an imaging technique that uses X-rays, and the radiation exposure is thought to be harmful to developing fetuses. Momentarily befuddled, I mumbled, “Uh, yeah ... ” It was clearly not the answer he’d anticipated, since he then asked, “Well, how pregnant are you?!” I told him 12 weeks. Sanitation measures were ceased, and the scrub nurse proceeded to shuttle me between operating rooms, each time stating, “Anna, here, is with child. Are you using X-rays?” Finally we settled on the cholecystectomy – a gallbladder removal – which was deemed to be a procedure appropriate for my delicate condition.

I proceeded through as many of the core clerkships – internal medicine, family medicine, surgery, emergency, obstetrics, pediatrics, psychiatry – as I could before my due date. Each one, I found, confirmed my decision. When I arrived to morning rounds, hoping I didn’t smell like my own vomit, I was thankful I wasn’t the intern or resident, responsible for more than twice my number of patients. During pediatrics, while gaining some perspective on how much energy these adorable little germ-bags consume, I considered that the sleep deprivation I experienced in med school had perhaps prepared me for something other than the sleep deprivation in residency. During obstetrics, the effects of age on fertility were drilled into us, and I was relieved that I wasn’t putting off a pregnancy until after I had completed residency in my mid- to late 30s.

Every woman is different, but we know that fecundability (the probability of achieving pregnancy in one menstrual cycle) begins to decline in the mid-20s, drops significantly in the early 30s and plummets a few years later, at about age 37. In the United States, an estimated 7 percent of married women ages 15 to 44 are infertile, and age is by far the most common cause of infertility in couples. That’s a problem, considering that over a third of college-educated women today have their first child at 30 or older.

There’s no solution for the fact that these childbearing years are also prime working years. But the truth is that whether they have children at 20 or 40, most women today don’t have a choice about working. I am fortunate enough to have a spouse who can temporarily support us, but we also have hundreds of thousands of dollars of student loans to pay off between the two of us. As one doctor told me, “I encourage my fellows to have children immediately if they want them. It doesn’t get any easier later, we just get older.” Far too often, women find out too late that they can’t have the children they wanted. Unlike hypothalamic amenorrhea, where the lack of a menstrual period is a clue that something is awry, many causes of infertility are symptomless, and almost 30 percent are unexplained. So in some ways I was lucky. If I hadn’t had to face my infertility, if the decision hadn’t been imposed on me so early, getting pregnant might have been considerably more complicated, probably requiring more invasive, time-intensive and expensive procedures. My pregnancy would be more likely to be fraught with complications, like hypertension, gestational diabetes and placental problems. My child would be more likely to have chromosomal abnormalities, most famously Down syndrome, or congenital malformations. Or pregnancy would simply no longer be an option. None of these possibilities would be made simpler by being further along in my career.

Without the diagnosis, I wouldn’t have chosen to have a child in the middle of my 20s, before even beginning my career, but it was the right path for me. And it might be the right path for more women, even those who don’t have any fertility problems.

Since the birth of my daughter, there have been instances when I’ve felt close to slamming my head through a window, but the last several months have also been some of the most fulfilling of my life. Holding her in my arms as a look of complete surprise flashes over her face when she feels a gust of wind for the first time, having her greet me with a smile, elatedly kicking her legs – it’s a privilege to experience such intense discovery and joy. I hope that my husband and I will be able to have more children, in med school, residency, or any time in our careers. I find comfort in the fact that school is there, waiting for me, exactly where I left it. For now, we’ve stopped worrying about convenience.