Today, we have two women physicians on the podcast to enlighten us about all things financial in relation to fertility treatments, which is a huge issue among physicians. They explain fertility challenges are twice as common among physicians as it is in the general population. Infertility treatments are mentally and physically taxing, not to mention really expensive. It is a complicated process in so many different ways. We are grateful to these two physicians for being willing to share their knowledge and their stories.
In This Show:
- Dr. Baker and Dr. Frieden's Infertility Journeys
- Cost of Infertility Treatments
- It Is Difficult for Physicians to Get to Infertility Appointments?
- How to Help Colleagues Going Through Infertility Treatments
- Why Is Infertility So High Among Female Physicians?
- Shop Around for the Best-Priced Clinic and Pharmacy
- Milestones to Millionaire Podcast
Dr. Baker and Dr. Frieden's Infertility Journeys
Dr. Disha Spath:
Today, we're going to be talking about a very important topic for women physicians in particular. It's very common among physicians, but unfortunately, it's not talked about very much. This is also something that really affects our finances, as well. It is an important thing for us to cover here at The White Coat Investor, and I am so thankful to welcome Dr. Dawn Baker and Dr. Natalie Frieden to share their information and journey with us. Welcome.
Dr. Dawn Baker:
Thank you so much.
Dr. Natalie Frieden:
Hi. Thank you for having us.
Dr. Disha Spath:
Absolutely. Dr. Baker, would you please tell us a little bit about yourself and your interest in this topic?
Dr. Dawn Baker:
Sure. I am an anesthesiologist. I've been in practice for a little bit over 10 years, and I have a long and roundabout history of infertility that started with having some problems during my residency. Anyone who has ever heard me speak or has read any of my writing knows that I suffered from a large pituitary adenoma that had to be surgically removed. The diagnosis of that was delayed by my own lack of self-awareness and self-care, which is the subject that I write about a lot in my blog and in other writings. The surgical removal of this tumor left me with permanent infertility. It was only found initially by me looking into my fertility when I turned about 35 years old. Long story short: after my tumor was removed and I was stabilized, I spent three years doing both IUI and IVF in order to have my daughter who is now 6 years old. I have recently embarked on another infertility journey that has been prolonged by COVID restrictions in which I am pursuing a surrogacy journey using a gestational carrier. We are going to be transplanting our only viable embryo later on this summer.
Dr. Disha Spath:
Wow, Dawn, thank you so much for being here and sharing that really difficult and long journey with us. I'm so excited to hear all the details and have you teach us about this really important topic. Dr. Natalie, can you please tell us a little bit about yourself and your journey?
Dr. Natalie Frieden:
As you can tell from my accent, I wasn't born in the US. I'm from Australia. I ended up completing my residency over in the Pacific Northwest and fellowship, but then moved down to the Southeast to be an attending. I'm an academic nephrologist. My husband and I are very fortunate that we have three children, but they were all conceived through fertility treatments. Kind of like Dawn, we didn't start until I was a little bit older at 35 years old. Until the first appointment with our REI specialist, I didn't realize that I had polycystic ovarian syndrome. Funny, two physician parents and no idea, it just wasn't on my radar that that could be an issue. Once we were diagnosed, we went through a lot of work to be able to conceive our three children. We were very, very lucky that it worked.
Dr. Disha Spath:
Wow. Sometimes we're so blind to our own health problems, just because we're so outwardly focused on giving as much as possible. It's a very important message that both of you are sharing for us to also look inwards and also have a doctor, right? So many doctors don't have doctors.
Dr. Jim Dahle:
Are we supposed to have a doctor? Nobody ever told me that. Well, they just changed the colonoscopy age. And so apparently, I'm in need of my first major visit to a doctor.
Dr. Disha Spath:
Oh, my goodness. Jim, we forgot about you. Sorry about that. Welcome to the podcast.
Dr. Jim Dahle:
I don't have an infertility journey to share, but I'm here because I'm super interested in this because this is a big problem among doctors. I get emails all the time from people asking “How do we deal with this? I don't have the money, but we know we don't want to wait any longer to start having our family. And this is going to cost us $30,000 or $40,000 to do this. And we don't even know if it's going to work.” This is a really important financial topic. I'm excited to do it on the podcast, even if it is not an area where I have any expertise whatsoever.
Dr. Disha Spath:
Well, thank you so much, Jim, for making this possible for us to discuss. Dawn, can you tell us a little bit about the background of infertility among physicians and why it's such a big problem?
Dr. Dawn Baker:
Infertility is actually really common just in the general population. It is estimated to be one in eight couples in the United States. We have limited data among physicians, but of the data that we do have, it is more common than that in women physicians. There are a few different studies that people point to, to give a number, but again, limited population studies, surveys mainly that have, as you can imagine, low response rates. The one study that's most often quoted lists a rate of 24% among women physicians. That's quite high.
Whatever the percentage is, even if it's one in eight or slightly more, it's still a very common thing. This is an issue because an infertility journey is very incompatible with a typical physician's work schedule. Then also the debt burden that we have as physicians is really high. It can be quite an expensive journey, as well.
Cost of Infertility Treatments
Dr. Disha Spath:
How much does a typical cycle cost?
Dr. Dawn Baker:
A typical IVF cycle, if you look at internet sources such as SART or ASRM or resolve.org—those are the typical infertility websites that people can resource—it is $10,000-$15,000, and that is not including medication. Your medications will cost you, on average, an extra, maybe $1,000-$2,000. It really depends on your infertility diagnosis and why you are pursuing infertility treatments as to the exact cost. As far as how many rounds you have to do, that has to do with your age and your diagnosis. So, there is such a wide range in how much people end up paying for this.
Dr. Disha Spath:
Natalie, how much did you end up paying?
Dr. Natalie Frieden:
It's kind of interesting. I started looking back at all of our medical bills going back since 2015. I was able to find bills for the IUI, meaning the intrauterine insemination cost for the ovulation induction. Without the medications, that's $300. The IUI procedure itself was $700. With monitoring and everything else you have to go through for one cycle, it ends up being about $1,700-$2,100 per cycle. That was what was quoted for us. Again, we were in different states, and every place is different.
The cost is different for IVF. We had to do in vitro fertilization with ICSI, so intracytoplasmic sperm injection. I'm not an REI specialist and I'm sorry for REIs who are listening out there if I stuffed up the way that I pronounced that. The estimate for one IVF retrieval—a transfer cycle with meds, the procedure, and the anesthesia—was between $16,000-$20,000. Then there's a storage fee associated with embryos and if you want to do embryo testing, which we did because I was older, cost us another $800. So, all in all, lots of money. I'm just going to say lots of money. By the time we went through everything and the medications, it was very expensive.
Dr. Disha Spath:
Does insurance cover this at all?
Dr. Natalie Frieden:
I think it depends on the insurance that you're with. Initially, we were under my husband's insurance, which was through the military, and they actually have an incredibly generous infertility availability. They covered most of it for the first two, for the IUI. It was the medications we had to pay out of pocket. IVF was different, though. Insurance paid for the initial consult. The initial consult would've been about $300, $400 and they paid for some labs and some procedures but not for the medications and not for the retrieval. So, I think with insurance, I'm looking here, the total was $14,000, and we got maybe $6,000 back. But I do remember we paid a lot more than that.
Dr. Jim Dahle:
It's interesting though. You mentioned IUI is dramatically cheaper than IVF.
Dr. Dawn Baker:
It is dramatically cheaper, but it also is dramatically less effective depending on your diagnosis and your age.
Dr. Disha Spath:
Dawn, can you break down these different methods of infertility treatments for us?
Dr. Dawn Baker:
Infertility treatments have a wide range of what is considered under that umbrella. It goes all the way from just taking medication to inducing ovulation, if you have irregular ovulation. That would be a very minimal cost. Then actually the next step would be intrauterine insemination, maybe using some injectable medications to regulate the cycle and then doing insemination up to IVF.
There's further testing as Natalie mentioned, like doing the genetic testing and then all the way up to using donor eggs, using donor sperm, or having a surrogate. You can consider adoption in some cases under infertility treatments if you're choosing to adopt based on your infertility treatment results. The range for that is from roughly $50,000-$100,000 per child for surrogacy and adoption type of situations. But it really is such a wide range of treatments, and it depends on why you have the problem.
It Is Difficult for Physicians to Get to Infertility Appointments?
Dr. Disha Spath:
Thank you so much for breaking all of that down. It sounds like there's a huge range of prices for all of this stuff. And it really depends on what the underlying issue is as to how much you end up paying.
I have the hardest time getting to a doctor, and we talked about how we don't go to the doctor often, right? Just making one appointment is very difficult when you're working as a working physician. With all these treatments, with the injections, and checking the labs, how are you even getting to all these appointments as a physician?
Dr. Dawn Baker:
That's a really good question. I want to mention one thing before we go onto this about insurance coverage. There are 16 states in this country out of 50 that mandate some level of insurance coverage for in vitro fertilization, and the others have no mandates. If you happen to live in one of those states, you have some level of coverage, but usually, it has a cap. It either has a dollar cap, or it has a number of cycles cap if you're talking about in vitro fertilization. Like Natalie mentioned, some of the things that she did when she was doing the IUIs were covered, and some of the things weren't. Just know there is a wide variety of coverages, as well.
Dr. Disha Spath:
I'm sure there could be some serious arbitrage if you wanted to move to those states. We move so much. If I were having that issue, I might consider it.
Dr. Natalie Frieden:
That was going to be one of the things I'd recommend. You can actually look around at the different costs. To answer your question about the difficulty of attending appointments, it is unbelievably involved. The beauty of it is that most of the appointments and the lab draws and ultrasounds are first thing in the morning, usually around 7:00 or 7:30, but I had to do the most incredible amount of shuffling of my clinic and my inpatient service. I had to share with a lot of my colleagues what we were doing because I needed to be covered. My husband works away a lot. When it came time for the embryo transfer, I actually had to have a friend come and pick me up and take me home, because you get propofol and can't drive. I had to take a day off work for that.
There is a lot involved. And every second day of a cycle, you are going back. And it's not just one cycle, it's over two cycles because you'll do the ovulation induction and then you need to rest everything. They may freeze the embryos, and then they implant the following month. It's very, very involved, a lot more involved than I recognized before we started. More so with the IVF than the IUI.
Dr. Dawn Baker:
Dr. Frieden talked about how the appointments are in the morning, well. As an anaesthesiologist, that didn't work for me at all. Because everybody has to be in the operating room at 7:00am, basically. Having the morning appointments isn't always useful for everyone if you are in an OR setting or a hospital setting vs. a clinic setting. Sixty-eight percent of the people that responded to my survey or that I interviewed about it, women physicians that are in practice, either in residency or attendings, said that they had difficulties scheduling their treatments around their work; 30% of the people said that they were either forced or they elected to decrease their work responsibilities or change their work in some way related to their infertility diagnosis.
How to Help Colleagues Going Through Infertility Treatments
Dr. Disha Spath:
Wow. That sounds like a double whammy. You're paying for all this stuff and you're going to cut your time back and not have the income coming in either. How can colleagues help? I know coverage is huge. How can we make it easier to share this with our colleagues?
Dr. Natalie Frieden:
I can answer that. I think the first thing is to be compassionate about it. If you know somebody who's going through infertility treatment, be kind to them and ask them how they're doing because the emotional toll is incredibly real. Even just talking about it now, even though we have three beautiful kids, I still get goosebumps thinking about the uncertainty of it. I think the thing is, we frequently worry as females in our 20s about kids. Then, it's this thing that you get to your mid to late 30s and you're like, “Oh my God, it's either now or never.” That time crunch really comes up. I think talking about it and recognizing that infertility is a really big problem for female physicians, especially, and we should really support it. If people want to have kids, we should support that because we'll always be doctors. We will always be doctors, but we won't always have the opportunity to have kids, and it can get really complicated. I think just really offering a lot of support, “How can I help you? What can I do to get you through this?”
Dr. Dawn Baker:
Along the same lines, I think it's important to be supportive without trying to offer advice. As physicians, we want to help people. We want to solve problems. But if you aren't going through infertility, you don't even really know what it's about. Or even if you have, it's just good to be open-ended with your support and not try to tell people what to do. We can also watch what we say, because it can be really hurtful and people are in a very emotional, vulnerable spot.
Some people really keep it a secret because they don't want to have these awkward conversations. However, I think that it's very important for all of our colleagues to be aware of this issue. This is a medical diagnosis and a medical issue, just like anything else. If a colleague of yours had cancer or if someone in their family was dying, you would help them. You would fill in for them, you would be flexible. That's what we need. We need awareness, and we need flexibility.
Dr. Disha Spath:
I love that. How can we get leadership to put policies in place that make this happen? That's the next step.
Dr. Natalie Frieden:
I thought a lot about this, and I think awareness is the first thing. I think that we need some really sensible maternity leave policies to encourage pregnancy earlier if somebody is interested. I know we delayed because I was in residency. My residency was great, but I was a resident and then I was in fellowship and there's never a good time to have a baby. I think we need support from all the different medical colleges, from the ABIM for me, from the ABEM for my husband, as an example, I think we need support from the GME officers because I've heard horror stories. One of our fellows told me he got two days paternity leave in his residency, which is just absurd. I think having physicians talk about it at wellness activities. We talk about finances all the time. We should be talking about infertility and the implications of that. I think also, like we mentioned before, some time off for medical leave that isn't going to then interrupt your IVU generation or your scheduling or that sort of thing.
Dr. Disha Spath:
Absolutely.
Dr. Dawn Baker:
Again, I think raising awareness to the fact that this is so common and it's even more common to some degree among physicians than the general population. If leaders know that, they can help to advocate for better insurance policies that do have some sort of coverage, that they have a culture of flexibility, not having punitive consequences for short-term absences, medical-related absences. I talked to people in my survey and also in my interviews that said that they had been reprimanded in their performance reviews in their job for too many unplanned absences and things like that. That's just unacceptable in this kind of case. If people realized how common this was and normalized it as a medical diagnosis, then I don't think that that would happen as often.
I believe that the culture of just having general wellness programs in place is very important because these women who are going through this need psychological support. We need to have employee-assistance programs, coaching available, support groups, if possible, and those are going to help everybody in the practice or in the institution. Also, another thing for raising awareness is have someone come and talk to your grand rounds or have an education program if you're in an academic program that is geared toward the residents and the medical students. I am happy to come to anybody's, or do a virtual presentation about this topic at anyone's grand rounds, if they are interested, because I think that will help to raise awareness, as well.
Dr. Disha Spath:
Thank you really, Dawn, for the work that you're doing. It's so important. Women physicians in general, we have a lot to offer, but unfortunately, because of the biological cycle, we need a lot of support early on because of childbearing and through infertility treatments, if necessary. But if people treat their employees right, and they take care of them, we have a very long career. I think it's so important for our entire system to realize that this is a change that needs to happen to sustain medicine for the future.
Dr. Dawn Baker:
Agree.
Dr. Natalie Frieden:
Agree.
Why Is Infertility So High Among Female Physicians?
Dr. Jim Dahle:
It's interesting. I mean, it's an epidemic among women physicians if it's 25%, when the normal rate in the population is half that. Has anybody looked into whether this is just age? Is it just that people aren't starting until they're 30 or 35 or 40? Or is there something else unique about being a physician that causes us to be much more likely to have this? Is it working night shifts? Is it having interrupted sleep from a call? Is it the stress of the job? Is there more to it than just starting late?
Dr. Dawn Baker:
I think there is, but the research or the literature is just not there at this point. I have combed the literature in order to give the talks that I've given and written the articles that I've written and the book chapter that I've written about this topic. There is just not a lot of information out there. There's no mechanistic data at all, but I do think that it's probably a combination of factors and age is one factor. There is data that shows that as physicians, we, on average, start our families at age 30, whereas the general population of US women is 26. Compare that to 50 years ago, I think it was 21 or 22. Then there are also factors in that we are, as a population, less healthy—however you define that at any given age than we used to be related to metabolic health, obesity rates, autoimmune disease, and different factors. Then you throw in the circadian rhythm disruption that physicians experience and the stresses that we have at work. You've basically got a perfect storm to have an increased risk for infertility. As far as the data goes, though, there's just not a lot out there yet.
Dr. Disha Spath:
Dawn, what are a couple of things you would tell younger doctors, younger med students to help try to avoid this problem?
Dr. Dawn Baker:
Well, it is hard, because the problem has so many different facets. There are the financial costs, there are the physical costs, the mental health costs. I would say that you want to think about having kids earlier, and that is a really difficult thing. I didn't do it. Natalie didn't do it. We were just talking about how we were in our mid-30s. It wasn't even on my radar. I didn't really realize. But if people know more how much their egg quality goes down as they get older, as just a function of age, regardless of how healthy you are, that might make you change your mind about when you want to build a family. There is no perfect time, and everyone knows that. In medical school, it's really hard. And in intern year and in residency, it's hard. But think about the other costs, if you wait, that might incur.
Also, consider cryopreservation of your eggs. There are some medical school and residency programs that are starting to educate their women physicians about this. It costs approximately one IVF cycle, like $10,000-$15,000. You could consider it an insurance policy. It's not a guarantee that you'll have a child, but it could help. If you already have a partner, you can do the cycle and then make embryos, which is even better than cryopreservation. Then all of the basic stuff that Jim talks about as a White Coat Investor. Make sure that your finances are optimized. Try to save as much money as you can, continue “living like a resident” when you're an attending, maximize your retirement savings, and make sure that you have an emergency fund. The most common way that the women who responded to my survey and my interviews finance their infertility is by using an emergency fund or just savings. You may have to change around and balance your budget and forgo your Tesla and forgo your nice doctor house for a little while longer.
Dr. Jim Dahle:
Well, you might have to forgo more than that. We recorded a podcast this morning. It ran a few weeks ago, those who are listening to this, but we talked about all the many things you need money for when you're becoming an attending. Remember this, Disha? We talked about emergency funds, and we talked about doing Roth conversions of your residency retirement accounts and saving up a down payment for your house and maxing out retirement accounts and that stuff. For a lot of couples, this is probably one of those big items as you're coming out of training to have some money set aside for IVF. If that means that you don't make a 401(k) contribution this year, well, maybe that's what it means. You have to decide your priorities and where you're going to put that money.
Dr. Natalie Frieden:
I was going to agree with Dawn about the finances, about having a separate account and just putting money into there. If you don't use it for that, great, you have a big chunk of change to throw in the market or build some other wealth. Just one other thing, stay off the internet. You read about all these stories about these women having babies in their 40s and 50s and whatever. It just does your head in, especially when you go through all the hormonal treatments. It just makes you feel very uncomfortable. So, get some really close friends and consider getting a counselor to help you through it, because the uncertainty of it is very, very difficult.
Shop Around for the Best-Priced Clinic and Pharmacy
Dr. Disha Spath:
That sounds horrible. Natalie, you had mentioned that you got fertility treatments in three different states. Can you tell us about the state-to-state variation that you encountered?
Dr. Natalie Frieden:
Sure. We were in Oregon, Washington, and then South Carolina. I think the biggest difference between them was actually going from one practice that was a university practice and the other two were private practices. That's where my husband and I noticed the difference. It was more that at a university practice, as you'd expect, things were a bit slower. Our lab results took longer. Those sorts of things. The private practices were well-oiled machines. We were in and out. We knew the email address for our nurses. It was just this very smooth and seamless process. In terms of the treatments, they were the same between the different states, and the cost of the medications were the same.
What was different was that the quote for IVF was less here than it was in the Northwest, which surprises me. That was one of the recommendations. It was if this is a path you need to go down, you can actually contact different clinics and find out how much they charge. If you have the means to be able to do it, if you wanted to save some money, you potentially could go to a different treatment facility in a different state. Because we're talking, it could end up costing tens of thousands of dollars. So that may be something you might want to think about.
Dr. Disha Spath:
What are the more frugal states to have fertility treatments?
Dr. Natalie Frieden:
From my personal experience, it seems like South Carolina was less expensive compared to the other ones, but the drugs were the same, because the drugs were shipped from different pharmacies. They were all shipped from New Jersey, but you can also shop around at the different pharmacies. There are different fertility pharmacies that will quote you different prices, which again, I never would've thought that there was even a business for this. But of course, there is.
Dr. Dawn Baker:
When I was doing my first infertility journey, I had really big medication costs because having hypopituitarism, I really needed a lot of stimulation and I had long cycles. They wanted to give me growth hormone on top of all the other stuff. Growth hormone in the typical pharmacy is $2,000 an injection. It is insane. I had a couple per cycle, but I did not shop around at medications and at pharmacies. I just got them from my university pharmacy where I was working. In retrospect, pharmacy arbitrage is big. You can find medications, even in different countries legitimately and other places.
There are medication exchanges where people had a canceled cycle and they don't need their medications anymore. You can get their medications either for a discounted rate, or they donate them. Sometimes your clinic or different clinics will have donated medications that aren't expired yet. Clinic arbitrage is a thing for sure as Natalie mentioned, but I do want to say as far as infertility getting in the way of your work-life balance, the closer your infertility clinic is, the easier it's going to be to manage your work schedule and manage your infertility treatments. If you can walk over there or if it's on-site, that is going to be big. You have to factor in that part of the cost. It's not all about the money cost.
Dr. Natalie Frieden:
Something that my husband and I ran into that was funny, consider the tax implications. Our last payment for our treatment was on December 31, 2020. When we were doing our taxes, we didn't realize we could have used that as part of our medical deduction. If we had waited one day, we could have used it the following year. Again, one of those things that was not on our radar. We could have waited a day. Somebody learn from that mistake.
Dr. Jim Dahle:
Let me ask you a question I've gotten several times over the years by email, and it basically comes from a doc often in training still. They say, we're trying to have a baby, it's not working. We're going to need some sort of assistance, IVF, or whatever. We don't have the money. Should we borrow for it? These are people that are going to be docs. They're going to have a high income eventually. What do you think about borrowing for something that's so uncertain but yet that is time-limited?
Dr. Natalie Frieden:
I can answer that one to start with. I think being in the position of really desperately wanting a child, I would've done anything. If finances were the thing that would've stopped me, I think I would've been very resentful of that later on in my career. I think you have to work out what your priority is because you can work as a physician and make all the money you like, but if you don't have the life that you foresee outside of medicine, then what's the point? I can understand why someone would take out a loan to go through something like this, because then at least you've tried. At the end of the day, it is just money and you will earn that money back at some point.
Dr. Dawn Baker:
I completely agree with you, Natalie. I tell people all the time, think about what your values are first. What is important to you at the end of the day? If that means that you're going to delay extra retirement contributions and things like that and you're going to take this loan out, then it's worth it to you. Having a child is priceless. That's what they say. A lot of the women that I interviewed, if they did a loan, they either did home equity line of credit, as long as they had that available to them. They also used other types of loans, such as using family or friends.
Dr. Jim Dahle:
I think some of these clinics will essentially let you finance it, correct?
Dr. Natalie Frieden:
Yes, that is also an option.
Dr. Jim Dahle:
Kind of like a lot of dental practices have financing programs that they brought in to help pay for things, I think a lot of the reproductive clinics have similar programs in place. Because think about it, if it's this hard for a doctor to do it, what's everybody else doing? They're financing it. It might be, if you have to do three or four cycles, this could be a high five-figure amount. It's not insignificant. Obviously, like any other loan, shop around and try to find the best terms and the best interest rates you can get for it. Whether that is a home equity line of credit or whether that's from the practice itself or any other source of borrowed funds that you might have; a 0% credit card for 15 months or something like that might work out. It just depends on what's available to you.
Dr. Disha Spath:
Ladies, thank you so much for sharing your journey with us and all of your valuable knowledge. I just feel like this is such an important part of our lives that just needs to be talked about. You are so brave for coming here and teaching us about infertility and all the obstacles and the ways we can optimize some of the treatments that we have to get. Thank you.
Dr. Jim Dahle:
That was great. That was really impressive that they were willing to be so vulnerable to come on here and talk about this.
Dr. Disha Spath:
Absolutely. It's such a brave thing to do. It's such a hard thing. I mean, kids and family are everything. Money is just a tool.
Dr. Jim Dahle:
It's interesting. We didn't have kids immediately when we got married. We got married fairly young. Maybe not by Utah standards, but by nationwide standards, I was 24 when I got married and Katie was younger. We waited about five years to have kids. I was an intern when we had our first child, but Katie was still mid-20s. But that is not the case for lots and lots and lots of docs. This is so common. People don't talk about it that much, but it's really common. I wouldn't have been surprised if somebody told me it was the majority of doctors that had some sort of fertility treatment. Because I feel like I talk to people all the time that have this issue and maybe not with the first couple of kids, maybe it's a later child. Maybe it's only the fourth one they needed assistance with.
Dr. Disha Spath:
I feel like for the first half of it was like, “Definitely do not get pregnant. Do not get pregnant.” You're just trying so hard. Then all of a sudden, you're like, OK, medical school, got to finish that. Then at the end of residency its suddenly, “I have to get pregnant right now!” because between residency and attending-hood is a great time to be on maternity leave. I don't know how we did it, but we planned it right. We were so, so lucky that it worked out, but it happened at the right time, right at the end of residency, right before entering my attending job. Then the second one happened during my attending job. That's probably how I would've liked to time it, but it was so difficult still, even then. It was so difficult. But the first maternity leave was completely unpaid, which was my financial awakening because it was tough.
The second maternity leave, again, being an attending and pumping, and let's talk about breastfeeding and how difficult that is. We should do that next time. But it's all very difficult in medicine to be a mother, to have a family and we just need to be aware of it and the process of making it more normal to talk about all of our struggles is what we need. Thank you, Jim, for making this possible.
Dr. Jim Dahle:
Maybe we need to normalize having family earlier in the process, because I think the normal thing right now is everyone says, “I'll have kids when I'm an attending.” Looking back, it's not that much easier as an attending other than the finances. It's not that much easier as an attending than it is as a fourth-year college student than it is as a first- or second-year medical student, even a fourth-year medical student. I'm not going to say it's easy to do during residency. That's certainly not the case, but maybe earlier in the process, if it was more normalized, then the percentages of docs needing these sorts of treatments would be lower. But instead, you have to be focused on your schooling, your career, and all that. Maybe we should be able to find a little better work-life balance earlier in the training pipeline.
Dr. Disha Spath:
Absolutely. And support our colleagues that have many different reasons for infertility. Dawn and Natalie were so good about sharing ways we can do that.
For anyone interested in additional resources you can visit Dr. Baker's website. She has a page dedicated to physician infertility resources, including books, websites, links, her coaching offerings, and more. You may also be interested in reading two of her recent articles that discussed the survey and interviews she referenced in the podcast. You can read those here and here.
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Full Transcript
Intro:
This is the White Coat Investor podcast, where we help those who wear the white coat get a fair shake on Wall Street. We've been helping doctors and other high-income professionals stop doing dumb things with their money since 2011.
Dr. Jim Dahle:
All right, your hosts today are Dr. Disha Spath and Dr. Jim Dahle. We are excited to bring this great episode to you. Welcome, Disha.
Dr. Disha Spath:
Thank you so much for having me.
Dr. Jim Dahle:
This is White Coat Investor podcast number 269 – Infertility among doctors.
Dr. Disha Spath:
Today's episode is sponsored by PearsonRavitz. PearsonRavitz are disability and life insurance advisors founded by and for physicians. This White Coat Investor recommended agency grew out of one MD's experience with a career-changing on-the-job injury.
Dr. Disha Spath:
Today, PearsonRavitz serves the medical community in all 50 states. At PearsonRavitz, they help you as a doctor safeguard your most valuable asset, your income so you can protect the most important people in your life, your family. PearsonRavitz makes human connections before they make quotes. Go to pearsonravitz.com to schedule your consultation with a PearsonRavitz advisor.
Dr. Disha Spath:
Our quote of the day today is “Focus on being balanced. Success is a balance.” That is said by Laila Ali.
Dr. Disha Spath:
That is so true, especially when we talk about families and being a physician and being money-wise, I think applies to all of it. And I think it is also a really good introduction to our guests today.
Dr. Jim Dahle:
Yeah. Great choice, Cindy, on picking that particular quote for today's episode.
Dr. Disha Spath:
Absolutely. So, we're going to have the author of Practice Balance Dr. Dawn Baker here with us today. Jim, do you want to tell them about that and then I'll tell them about our conference coming up?
Dr. Jim Dahle:
Sure. Sure. We've got a great episode today. We've got a couple of women physicians that are coming on today and are going to enlighten us about all things financial in relation to fertility treatments, which is a huge issue among physicians. It's about twice as frequent, we're going to learn among physicians as it is in the general population, and it's really expensive. And there's a lot of financial aspects to it, as well as non-financial aspects to it.
Dr. Jim Dahle:
So, we're excited to have a pretty awesome episode today, all about this topic. But we'll bring them on the line in just a moment. Before we do that, why don't you tell people how they can potentially even come meet these people in person? Because I think one of them may very well be at WCICON 2023. She's spoken at a couple of our other episodes or our other conferences.
Dr. Disha Spath:
Absolutely. Dr. Dawn Baker actually gave a great talk on this topic at WCICON22, and I hope she'll come back for 23. WCICON23 speaker application is due now guys. If you guys want to talk at the conference, come because it is so fun. We had such a great time last year. The hotel was amazing. The food was amazing. The talks were amazing.
Dr. Disha Spath:
There's so much learning going on and there's really nothing like just being around like-minded people and especially people in the finance world, doctors that are interested in finance, it's just hard to find. And the fact that we can all get together and nerd out together is so great. So come, apply to be a speaker. And there are perks of coming free that way. It's frugal.
Dr. Jim Dahle:
Yeah, yeah, for sure. The conference is worth paying for, don't get me wrong. This is a great conference. You should totally pay when we open it up to applications this fall. You should come to the conference.
Dr. Disha Spath:
100%.
Dr. Jim Dahle:
But if you want to come free and you actually want to get paid to be there, you got to be a speaker. So, this is your chance to come to WCICON free, by applying today at www.wcievents.com.
Dr. Jim Dahle:
All right. I think that's probably enough for now. Let's get them on the line and let's get into our content.
Dr. Disha Spath:
Okay. Today we're going to be talking about a very important topic for women physicians in particular. This is one thing that exists in our community. It's very common, but unfortunately, it's not very talked about. And unfortunately, it also really affects our finances. So, it's an important thing for us to cover here at the White Coat Investor today. I am so thankful to welcome Dr. Dawn Baker and Dr. Natalie Frieden to share their information and journey with us. Welcome.
Dr. Dawn Baker:
Thank you so much.
Dr. Natalie Frieden:
Hi. Thank you for having us.
Dr. Disha Spath:
Absolutely. Dr. Dawn Baker, would you please tell us a little bit about yourself and your interest in this topic?
Dr. Dawn Baker:
Sure. I am an anesthesiologist. I've been in practice for a little bit over 10 years and I have a long and roundabout history of infertility that started with having some problems during my residency. And if anyone has ever heard me speak or has read any of my writing knows that I suffered from a large pituitary adenoma that had to be surgically removed.
Dr. Dawn Baker:
And the diagnosis of that was delayed by my own lack of self-awareness and self-care, which is the subject that I write about a lot in my blog and in other writings. And the surgical removal of this tumor left me with permanent infertility. And it was only found initially by me looking into my fertility when I turned about 35 years old.
Dr. Dawn Baker:
So, long story short after my tumor was removed and I was stabilized, I spent three years doing both IUI and IVF in order to have my daughter who is now six years old. And I have recently embarked on another infertility journey that has been prolonged by COVID restrictions in which I am pursuing a surrogacy journey using a gestational carrier.
Dr. Disha Spath:
Wow.
Dr. Dawn Baker:
Yes. And we are going to be transplanting our only viable embryo later on this summer.
Dr. Disha Spath:
Wow, Dawn, thank you so much for being here and sharing that really difficult and long journey with us. I'm so excited to hear all the details and have you teach us about this really important topic. Dr. Natalie, can you please tell us a little bit about yourself and your journey?
Dr. Natalie Frieden:
Sure. As you can tell from my accent, I wasn't born in the US, I'm from Australia. I ended up completing my residency over in the Pacific Northwest and fellowship, but then moved down to the Southeast to be an attending. I'm an academic nephrologist.
Dr. Natalie Frieden:
My husband and I are very fortunate that we have three children, but they were all conceived through fertility treatments. Kind of like Dawn, we didn't start until I was a little bit later until I was 35 years old. And until the first appointment with our REI specialist, I didn't realize that I had polycystic ovarian syndrome. Funny, two physician parents, no idea, just wasn't on my radar that that could be an issue. And then once we were diagnosed, we went through a lot of work to be able to conceive our three children. We were very, very lucky that they worked.
Dr. Disha Spath:
Wow. Yeah. Sometimes we're so blind to our own health problems just because we're so outwardly focused on giving as much as possible. It's a very important message that both of you are sharing for us to also look inwards and also have a doctor, right? So many doctors don't have doctors.
Dr. Jim Dahle:
Are we supposed to have a doctor? Nobody ever told me that.
Dr. Natalie Frieden:
You sound like my husband now.
Dr. Jim Dahle:
Well, they just changed the colonoscopy age. And so apparently, I'm in need of my first major visit to a doctor.
Dr. Natalie Frieden:
I joke that I'm a nephrologist and I told my husband the other day, we were buying a blood pressure machine and he said, “For you?” I was like, “No, for you.” So, I get it.
Dr. Disha Spath:
Oh, my goodness. Well, yeah, Jim, we forgot about you. Sorry about that. Welcome to the podcast.
Dr. Jim Dahle:
I don't have an infertility journey to share, but I'm here because I'm super interested in this because this is a big problem among doctors. I get emails all the time from people asking “How do we deal with this? I don't have the money, but we know we don't want to wait any longer to start having our family. And this is going to cost us $30,000 or $40,000 to do this. And we don't even know if it's going to work.” So, this is a really important financial topic. I'm excited to do it on the podcast, even if it is not an area where I have any expertise whatsoever.
Dr. Disha Spath:
Well, thank you so much, Jim, for making this possible for us to discuss. Dawn, can you tell us a little bit about the background of infertility among physicians and why it's such a big problem?
Dr. Dawn Baker:
Sure. Infertility is actually really common just in the general population. It is estimated to be one in eight couples in the United States, and we have limited data among physicians, but of the data that we do have, it is more common than that in women physicians. And there are a few different studies that people point to, to give a number, but again, limited populations studies, surveys mainly that have, as you can imagine, low response rates. So, the one study that's most often quoted lists a rate of 24% among women physicians. So that's quite high.
Dr. Disha Spath:
Wow. Yeah.
Dr. Dawn Baker:
Whatever it is, whatever the percentage is, even if it's one in eight or slightly more, it's still a very common thing. And this is an issue because an infertility journey is very incompatible with a typical physician's work schedule. And then also the debt burden that we have as physicians is really high. And then it can be quite an expensive journey as well.
Dr. Disha Spath:
Yeah. So how much does a typical cycle cost?
Dr. Dawn Baker:
A typical IVF cycle, if you look at internet sources such as SART or ASRM or resolve.org, those are like the typical infertility websites that people can resource, it is $10,000 to $15,000, and that is not including medication. So, your medications will cost you on average an extra, maybe $1,000 to $2,000. And it really depends on your infertility diagnosis, why you are pursuing infertility treatments as to the exact cost.
Dr. Dawn Baker:
And then as far as how many rounds you have to do, that has to do with your age, has to do with your diagnosis. So, there is such a wide range in how much people end up paying for this.
Dr. Disha Spath:
Oh, my goodness. Natalie, how much did you end up paying?
Dr. Natalie Frieden:
It's kind of interesting. I started looking back at all of our medical bills going back since 2015. And I was able to find for the IUI. So, the intrauterine insemination cost for the ovulation induction. Without the medications that's $300. The IUI procedure itself was $700. And then with monitoring and everything else, you have to go through for one cycle, it ends up being about $1,700 to $2,100 per cycle. That was what was quoted for us. And again, we were in different states, every place is different. So that was for IUI.
Dr. Natalie Frieden:
And then for IVFs. We had to do in vitro fertilization with ICSI, so intracytoplasmic sperm injection. I'm not an REI specialist and I'm sorry for REIs who are listening out there if I stuffed up the way that I pronounced that.
Dr. Natalie Frieden:
But I actually found out the cost for everything. The estimate for one IVF retrieval—a transfer cycle with meds, the procedure, the anaesthesia was between $16,000 and $20,000. And then there's a storage fee associated with embryos. And then if you want to do embryo testing, which we did because I was older, cost us another $800. So, all in all, lots of money. I'm just going to say lots of money. By the time we went through everything and the medications, it was very expensive.
Dr. Disha Spath:
Yeah. Does insurance cover this at all?
Dr. Natalie Frieden:
I think it depends on the insurance that you're with. Initially, we were under my husband's insurance, which was through the military and they actually have an incredibly generous infertility availability. They covered most of it for the first two, for the IUI. It was the medications we had to pay out of pocket.
Dr. Natalie Frieden:
For IVF was different though. Insurance paid for the initial consult. So, the initial consult would've been about $300, $400 and they paid for some labs and some procedures, but not for the medications, and not for the retrieval. So, I think with insurance, I'm looking here, the total was $14,000 and we got maybe $6,000 back. But I do remember we paid a lot more than that.
Dr. Jim Dahle:
It's interesting though. You mentioned IUI is dramatically cheaper than IVF.
Dr. Dawn Baker:
It is dramatically cheaper, but it also is dramatically less effective depending on your diagnosis and your age.
Dr. Disha Spath:
Dawn, can you break down these different methods of infertility treatments for us real fast?
Dr. Dawn Baker:
Well, infertility treatments have a wide range of what is considered under that umbrella. And it goes all the way from just taking medication to induce ovulation, if you have irregular ovulation. So that would be a very minimal cost. And then actually the next step would be like intrauterine insemination, maybe using some injectable medications to regulate the cycle and then doing insemination up to IVF.
Dr. Dawn Baker:
And then there's further testing as Natalie mentioned, like doing the genetic testing and then all the way up to using donor eggs, using donor sperm, having a surrogate. And then you can consider adoption in some cases under infertility treatments, if you're choosing to adopt based on your infertility treatment results. So, that can go up to, the range is up to like $50,000 to $100,000 per child for surrogacy and adoption type of situations. But it really is such a wide range of treatments and it depends on why you have the problem.
Dr. Disha Spath:
Wow. Thank you so much for breaking all of that down. And it sounds like there's a huge range of prices for all of this stuff. And it really depends on what the underlying issue is as to how much you end up paying.
Dr. Disha Spath:
I'm just thinking, I have the hardest time getting to a doctor and we talked about how we don't go to the doctors, right? Just making one appointment is very difficult when you're working as a working physician. With all these treatments, with the injections, and checking the labs and stuff, how are you even getting to all these appointments as a physician?
Dr. Dawn Baker:
That's a really good question. I want to mention one thing before we go onto this about insurance coverage. There are 16 states in this country out of 50 that mandates some level of insurance coverage for in vitro fertilization, and the others have no mandates.
Dr. Dawn Baker:
So, if you happen to live in one of those states, you have some level of coverage, but there usually has a cap. It either has a dollar cap, or it has a number of cycle cap if you're talking about in vitro fertilization, or like as Natalie mentioned, some of the things that she did when she was doing the IUIs were covered and some of the things weren't. So, before we move on, there's a wide variety of coverages as well.
Dr. Disha Spath:
Thank you so much for sharing that. I'm sure there could be some serious arbitrage if you wanted to move to those states. We move so much. If I were having that issue, I might consider it.
Dr. Natalie Frieden:
That was going to be one of the things I'd recommend that you can actually look around at the different costs, but we can talk about it at the end. To answer your question about how it is involved, it is unbelievably involved. The beauty of it is that most of the appointments and the lab draws and ultrasounds are first thing in the morning, usually around 7:00 or 7:30, but I had to do the most incredible amount of shuffling of my clinic, of my inpatient service.
Dr. Natalie Frieden:
I had to share with a lot of my colleagues what we were doing because I needed to be covered. My husband works away a lot. And so, when it came time for the embryo transfer, I actually had to have a friend come and pick me up and take me home because you get propofol. I can't drive. So, I had to take a day off work for that.
Dr. Natalie Frieden:
There is a lot involved. And every second day of a cycle, you are going back. And it's not just one cycle, it's over two cycles because you'll do the ovulation induction and then you need to rest everything. They may freeze the embryos, and then they replant the following month. And it's very, very involved, a lot more involved than I recognized before we started. More so even the IVF than the IUI.
Dr. Disha Spath:
Wow.
Dr. Dawn Baker:
I recently gave a talk on this subject, the epidemic of physician infertility at the WCICON in 2022, as you guys know.
Dr. Disha Spath:
Which was awesome.
Dr. Dawn Baker:
Thank you. I interviewed basically through a survey and then also face to face a lot of women physician colleagues. Over 150 people responded to an anonymous survey that I put out and I asked them about how they dealt with this issue.
Dr. Dawn Baker:
And it was by far and away, the most problematic thing of going through infertility for physicians, which was trying to shuffle their schedule and manage their work schedule around these treatments because they are very short notice. They change on a dime based on the results of the appointment that you go to that day. You may have to go the next morning, or it may be the next morning.
Dr. Dawn Baker:
So, you can imagine that having your patient load or being like you talked about how the appointments are in the morning, well, as an anaesthesiologist, that didn't work for me at all. Because everybody has to be in the operating room at 7:00 AM, basically. And so having the morning appointments isn't always useful for everyone if you are in an OR setting or a hospital setting versus a clinic setting.
Dr. Dawn Baker:
And 68% of the people that responded to my survey or that I interviewed about, these are women physicians that are in practice, either in residency or attendings, said that they had difficulties scheduling their treatments around their work. And 30% of the people said that they were either forced or they elected to decrease their work responsibilities or change their work in some way related to their infertility diagnosis.
Dr. Disha Spath:
Wow. Yeah, that sounds like a double whammy, you're paying for all this stuff, and you're going to cut your time back and not have the income coming in either. So, how can colleagues help? I know coverage is huge. How can we make it easier to share this with our colleagues?
Dr. Natalie Frieden:
I can answer that. I think the first thing is to be compassionate about it. If you know somebody who's going through infertility treatment, be kind to them and ask them how they're doing because the emotional toll is incredibly real. Even just talking about it now, even though we have three beautiful kids, I still get goosebumps thinking about the uncertainty of it.
Dr. Natalie Frieden:
And I think the thing is we frequently worry as females in our 20s, worrying about kids. And then it's this thing that you get to your mid to late 30s. And you're like, “Oh my God, it's either now or never.” And that time crunch really comes up. So, I think talking about it and recognizing that infertility is a really big problem for female physicians, especially, and we should really support it. If people want to have kids, we should support that because we'll always be doctors. We will always be doctors, but we won't always have the opportunity to have kids and it can get really complicated. So, I think just really offering a lot of support, “How can I help you? What can I do to get you through this?”
Dr. Dawn Baker:
Along the same lines, I think it's important to be supportive without trying to offer advice. And as physicians, we want to help people, we want to solve problems, but if you aren't going through infertility, you don't even really know what it's about. Or even if you have, it's just good to be open-ended with your support and not try to tell people what to do, watch what you say, because it can be really hurtful and people are in a very emotional, vulnerable spot.
Dr. Dawn Baker:
Some people really keep it a secret because they don't want to have these awkward conversations. However, I think that it's very important for all of our colleagues to be aware of this issue. This is a medical diagnosis and a medical issue just like anything else. If a colleague of yours had cancer, or if someone in their family was dying, you would help them. You would fill in for them, you would be flexible. So, that's what we need. We need awareness and we need flexibility.
Dr. Disha Spath:
I love that. Yeah, absolutely. And how can we get leadership to put in policies in place that make this happen? That's the next step.
Dr. Natalie Frieden:
I thought a lot about this and I think awareness is the first thing. I think that we need some really sensible maternity leave policies to encourage pregnancy earlier if somebody is interested because I know we delayed because I was in residency. My residency was great, but I was a resident and then I was in fellowship and there's never a good time to have a baby.
Dr. Natalie Frieden:
I think we need support from all the different medical colleges from the ABIM for me, for the ABEM and for my husband as example, I think we need support from the GME officers because I've heard horror stories. One of our fellows told me he got two days paternity leave in his residency which is just absurd.
Dr. Natalie Frieden:
I think having physicians talk about it at wellness activities. We talk about finances all the time. We should be talking about infertility and the implications of that. And I think also like we mentioned before, some time off for medical leave that isn't going to then interrupt your IVU generation or your scheduling or that sort of thing.
Dr. Disha Spath:
Absolutely.
Dr. Dawn Baker:
Yeah. I think raising awareness again to the fact that this is so common and it's even more common to some degree than the general population among physicians. And if leaders know that, they can help to advocate for better insurance policies that do have some sort of coverage that they have a culture of flexibility, not having punitive consequences for short-term absences, medical-related absences.
Dr. Dawn Baker:
I talked to people in my survey and also in my interviews that said that they had been reprimanded in their performance reviews in their job for too many unplanned absences and things like that. And that's just unacceptable in this kind of case. If people realized how common this was and normalized it as a medical diagnosis, then I don't think that that would happen as often.
Dr. Dawn Baker:
And then I believe that the culture of just having general wellness programs in place is very important because these women who are going through this need psychological support. We need to have employee assistance programs, coaching available, support groups, if possible, and those are going to help everybody in the practice or in the institution.
Dr. Dawn Baker:
Also, another thing for raising awareness is have someone come and talk to your grand rounds or have an education program if you're in an academic program that is geared toward the residents and the medical students. I am happy to come to anybody's or do a virtual presentation about this topic at anyone's grand rounds, if they are interested, because I think that will help to raise awareness as well.
Dr. Disha Spath:
Thank you really, Dawn, for the work that you're doing. It's so important. Women physicians in general, we have a lot to offer, but unfortunately, because of the biological cycle, we need a lot of support early on because of the childbearing and through infertility treatments, if necessary.
Dr. Disha Spath:
But if people treat their employees right, and they take care of them, we have a very long career. We tend to be way more productive in the later stages of our life. And I think it's so important for our entire system to realize that this is a change that needs to happen to sustain medicine for the future.
Dr. Dawn Baker:
Agree.
Dr. Natalie Frieden:
Agree.
Dr. Jim Dahle:
It's interesting. I mean, it's also an epidemic among women physicians if it's 25%, when the normal rate in the population is half that. Has anybody looked into whether this is just age? Is it just that people aren't starting until they're 30 or 35 or 40? Or is there something else unique about being a physician that causes us to be much more likely to have this? Is it working night shifts? Is it having interrupted sleep from a call? Is it the stress of the job? Is there more to it than just starting late?
Dr. Disha Spath:
That's a good point.
Dr. Dawn Baker:
I think there is, but the research or the literature is just not there at this point. I have combed the literature in order to give the talks that I've given and written the articles that I've written in the book chapter that I've written about this topic. And there is just not a lot of information out there. There's no mechanistic data at all, but I do think that it's probably a combination of factors and age is one factor.
Dr. Dawn Baker:
There is data that shows that as physicians, we, on average, start our families at age 30, whereas the general population of US women is 26. And compare that to 50 years ago, I think it was 21 or 22. So everybody has changed their age.
Dr. Dawn Baker:
But then there are also factors in the fact that we are, as a population, less healthy however you define that at any given age than we used to be related to metabolic health, obesity rates, autoimmune disease, and different factors. And then you throw in the circadian rhythm disruption that physicians experience and the stresses that we have at work. And you've basically got a perfect storm to have an increased risk for infertility. Now, as far as the data though goes, there's just not a lot out there yet.
Dr. Disha Spath:
Dawn, what are a couple of things you would tell younger doctors, younger med students coming through to try to avoid or to try to increase their fertility, I guess. That sounds weird. But what are the best things to do to try to avoid this problem?
Dr. Dawn Baker:
Well, because the problem has so many different facets, there's the financial costs, there's the physical costs, the mental health costs. I would say that you want to think about having kids earlier, and that is a really difficult thing. I didn't do it. Natalie didn't do it. We were just talking about how we were in our mid-30s. It wasn't even on my radar. I didn't really realize.
Dr. Dawn Baker:
But if people know more how much their egg quality goes down as they get older, as just a function of age, regardless of how healthy you are, that might make you change your mind about when you want to build a family. There is no perfect time and everyone knows that. In medical school, it's really hard. And in intern year and in residency, it's hard. But think about the other costs if you wait that might incur.
Dr. Dawn Baker:
Also, consider cryopreservation of your eggs. There are some medical school and residency programs that are starting to educate their women physicians about this. It costs approximately one IVF cycle, like $10,000 to $15,000. You could consider it an insurance policy. It's not a guarantee that you'll have a child, but it could help. If you already have a partner, you can do the cycle and then make embryos that's even better than cryopreservation.
Dr. Dawn Baker:
And then all of the basic stuff that Jim talks about as a White Coat Investor to make sure that your finances are optimized. Try to save as much money as you can, continue “living like a resident” when you're attending, maximize your retirement savings, and make sure that you have an emergency fund.
Dr. Dawn Baker:
The most common way that the women who responded to my survey and my interviews finance their infertility is by using an emergency fund or just savings that they saved. And you may have to change around and balance your budget and forgo your Tesla and forego your nice doctor house for a little while longer.
Dr. Jim Dahle:
Well, you might have to forgo more than that. We recorded a podcast this morning. It ran a few weeks ago, those who are listening to this, but we talked about all the many things you need money for when you're becoming an attending. Remember this, Disha? We talked about emergency funds and we talked about doing Roth conversions of your residency retirement accounts and saving up a down payment for your house and maxing out retirement accounts and that stuff.
Dr. Jim Dahle:
For a lot of couples, this is probably one of those big items as you're coming out of training to have some money set aside for IVF. And if that means that you don't make a 401(k) contribution this year, well, maybe that's what it means. And you have to decide your priorities and where you're going to put that money.
Dr. Disha Spath:
Absolutely.
Dr. Natalie Frieden:
I was going to agree with Dawn about the finances, about having a separate account and just putting money into there. And if you don't use it for that, great, you have a big chunk of change to throw in the market or build some other wealth.
Dr. Natalie Frieden:
And just one other thing, stay off the internet. You read about all these stories about these women having babies in their 40s and 50s and whatever. It just does your head in, especially when you go through all the hormonal treatments, it just makes you feel kind of, I don't want to say crazy. It just makes you feel very uncomfortable. So, get some really close friends and consider getting a counsellor to help you through it because it's just that the uncertainty of it is very, very difficult.
Dr. Disha Spath:
That sounds horrible. Natalie, you had mentioned that you got fertility treatments in different states, in three different states. Can you tell us about the state-to-state variation that you encountered?
Dr. Natalie Frieden:
Sure. We were in Oregon, Washington, and then South Carolina. And I think the biggest difference between them was actually going from one practice was a university practice. And the other two were private practices. That's where my husband and I noticed the difference. It was more that at a university practice, as you'd expect, things were a bit slower. Our lab results took longer. Those sorts of things.
Dr. Natalie Frieden:
The private practices were well-oiled machines. We were in and out. We knew the email address for our nurses. It was just this very smooth and seamless process. So, in terms of the treatments, they were the same between the different states and the cost of the medications were the same.
Dr. Natalie Frieden:
What was different was that the quote for IVF was less here than it was in the Northwest, which surprises me. That was one of the recommendations. It was if this is a path you need to go down, you can actually contact different clinics and find out how much they charge. And if you have the means to be able to do it, if you wanted to save some money, you potentially could go to a different treatment facility in a different state. Because we're talking, it could end up costing tens of thousands of dollars. So that may be something you might want to think about.
Dr. Disha Spath:
So, what are the more frugal states to have fertility treatments?
Dr. Natalie Frieden:
Well, just from my only personal experience, it seems like South Carolina was less expensive compared to the other ones, but the drugs were the same, because the drugs were shipped from different pharmacies. They were all shipped from, I think, New Jersey, but you can also shop around at the different pharmacies. There are different fertility pharmacies that will quote you different prices, which again, I never would've thought that there was even a business for this. But of course, there is.
Dr. Dawn Baker:
When I was doing my first infertility journey, I had really big medication costs because having hypopituitarism, I really needed a lot of stimulation and I had long cycles. And they wanted to give me growth hormone on top of all the other stuff. Growth hormone in the typical pharmacy is $2,000 an injection.
Dr. Disha Spath:
Wow.
Dr. Dawn Baker:
That is insane. I had like a couple per cycle, but I did not shop around at medications and at pharmacies, I just got them from my university pharmacy where I was working. And in retrospect, pharmacy arbitrage is big. You can find medications, even in different countries legitimately and other places.
Dr. Dawn Baker:
There are medication exchanges where people had a cancelled cycle and they don't need their medications anymore. And you can get their medications either for a discounted rate or they donate them. Sometimes your clinic, or different clinics will have donated medications that aren't expired yet. So, you can go that way.
Dr. Dawn Baker:
And clinic arbitrage is a thing for sure as Natalie mentioned, but I do want to say as far as infertility getting in the way of your work-life balance, the closer your infertility clinic is, the easier it's going to be to manage your work schedule and manage your infertility treatments. If you can walk over there or if it's on-site, that is going to be big. So, you have to factor in that part of the cost. It's not all about the money cost.
Dr. Natalie Frieden:
Something that my husband and I ran into that was funny, consider the tax implications. Our last payment for our treatment was on December 31st, 2020. And when we were doing our taxes, we didn't realize we could have used that as part of our medical deduction. So, if we had waited one day, we could have used it the following day. Again, one of those things that was not on our radar, we could have waited a day. So, somebody learn from that mistake.
Dr. Jim Dahle:
Sounds like all the people getting induced on December 31st to try to get that tax deduction. Let me ask you a question I've gotten several times over the years by email, and it basically comes from a doc often in training still. And they say, we're trying to have a baby, it's not working. We're going to need some sort of assistance, IVF, whatever. We don't have the money. Should we borrow for it?
Dr. Jim Dahle:
And these are people that are going to be docs. They're going to have a high income eventually. What do you think about borrowing for something that's so uncertain, but yet that is time-limited?
Dr. Natalie Frieden:
I can answer that one to start with. I think being in the position of really desperately wanting a child, I would've done anything. And if finances were the thing that would've stopped me, I think I would've been very resentful of that later on my career.
Dr. Natalie Frieden:
So, I think you have to work out what your priority is because you can work as a physician and make all the money you like, but if you don't have the life that you foresee outside of medicine, then what's the point?
Dr. Natalie Frieden:
I can understand why someone would take out a loan to go through something like this, because then at least you've tried. At the end of the day, it is just money and you will earn that money back at some point.
Dr. Dawn Baker:
I completely agree with you, Natalie. I tell people all the time, think about what your values are first. What is important to you at the end of the day? And if that means that you're going to delay extra retirement contributions and things like that, and you're going to take this loan out, then it's worth it to you.
Dr. Dawn Baker:
Having a child is priceless. That's what they say. And a lot of the women that I interviewed, if they did a loan, they either did home equity line of credit, as long as they had that available to them. And then, other types of loans such as using family or friends too, are a possibility.
Dr. Jim Dahle:
Now, I think some of these clinics will essentially let you finance it, correct?
Dr. Natalie Frieden:
It's also an option.
Dr. Jim Dahle:
Kind of like a lot of dental practices have financing programs that they brought in to help pay for things. I think a lot of the reproductive clinics have similar programs in place. Because think about it, if it's this hard for a doctor to do it, what's everybody else doing? They're financing it, they're financing it. And it might be, if you got to do three or four cycles, this could be a high five-figure amount. It's not insignificant.
Dr. Jim Dahle:
So, obviously, like any other loan, shop around and try to find the best terms and the best interest rates you can get for it. Whether that is a home equity line of credit or whether that's from the practice itself or any other source of borrowed funds that you might have. 0% credit card for 15 months or something like that might work out. It just depends on what's available to you.
Dr. Disha Spath:
Ladies, thank you so much for sharing your journey with us and all of your valuable knowledge. I just feel like this is such an important part of our lives that just needs to be talked about. And you guys are so brave for coming here and teaching us about infertility and all the obstacles and the ways we can optimize some of the treatments that we have to get. So, thank you.
Dr. Dawn Baker:
Thank you so much for having us. This is such an important topic.
Dr. Disha Spath:
Yeah. Absolutely.
Dr. Natalie Frieden:
Thank you for having us.
Dr. Jim Dahle:
All right. That was great. That was really impressive, actually. I thought that they were willing to be so vulnerable to come on here and talk about this.
Dr. Disha Spath:
Absolutely. Yeah. It's such a brave thing to do. It's such a hard thing. I mean, kids and family are everything. Money is just a tool.
Dr. Jim Dahle:
Yeah. It's interesting, we didn't have kids immediately when we got married, we got married fairly young. Maybe not by Utah standards, but by nationwide standards, I was 24 when I got married and Katie was younger. And we waited about five years. I was an intern when we had our first child, but Katie was still mid-20s when we had our first child. And so, we had the opposite problem. We didn't have kids when we didn't want them.
Dr. Jim Dahle:
But that is not the case for lots and lots and lots of docs. This is so common. People don't talk about it that much, but it's really common. I wouldn't have been surprised if somebody told me it was the majority of doctors that had some sort of fertility treatment. Because I feel like I talk to people all the time that have this issue and maybe not with the first couple of kids, maybe it's a later child. Maybe it's only the fourth one they needed assistance with.
Dr. Disha Spath:
Absolutely. I feel like in my life, for the first half of it was like, “Definitely do not get pregnant. Do not get pregnant.” And you're just trying so hard. And then all of a sudden, you're like, okay, medical school, got to finish that. But now at the end of residency, “I got to get pregnant right now” because between residency and attending hood is a great time to be on maternity leave.
Dr. Disha Spath:
So, I don't know how we did it, we planned it right. And we were so, so lucky that it worked out, but it happened at the right time, right at the end of residency, right before entering my attending job.
Dr. Disha Spath:
And then the second one happened during my attending job. And that's probably how I would've liked to time it, but it was so difficult still, even then, even so. It was so difficult. But the first maternity leave was completely unpaid, which you know my story and that was my financial awakening because it was tough.
Dr. Disha Spath:
And the second maternity leave, again, being an attending and pumping, and let's talk about breastfeeding and how difficult that is. We should do that next time. But it's all very difficult in medicine to be a mother, to have a family and we just need to be aware of it and the process of making it more normal to talk about all of our struggles is what we need. So, thank you, Jim, for making this possible.
Dr. Jim Dahle:
Yeah. Maybe we need to normalize having more family earlier in the process, because I think the normal thing right now is everyone says, “Well, I'll have kids when I'm an attending.”
Dr. Disha Spath:
Yeah.
Dr. Jim Dahle:
And looking back, it's not that much easier as an attending other than the finances. It's not that much easier as an attending than it is as a fourth-year college student than it is as a first or second-year medical student, even a fourth-year medical student.
Dr. Jim Dahle:
I'm not going to say it's easy to do during residency. That's certainly not the case, but maybe earlier in the process, if it was more normalized, then the percentages of docs needing these sorts of treatments would be lower. But instead, you got to be focused on your schooling, your career, and all that. And maybe we should be able to find a little better work-life balance earlier in the training pipeline.
Dr. Disha Spath:
Right. Right. Absolutely. And support our colleagues that have many different reasons for infertility. And Dawn and Natalie were so good about sharing ways we can do that without saying the wrong thing. Because I tend to put my foot in my mouth a lot.
Dr. Jim Dahle:
Exactly. Exactly.
Dr. Disha Spath:
Yeah.
Dr. Jim Dahle:
All right. Well, why don't you tell them about our sponsor today who is another woman physician?
Dr. Disha Spath:
Yes, I would love to. Our sponsor today is PearsonRavitz. PearsonRavitz are disability and life insurance advisors founded by and for physicians. This White Coat Investor recommended agency grew out of one MD's experience with a career-changing on-the-job injury.
Dr. Disha Spath:
Today, PearsonRavitz serves the medical community in all 50 states. At PearsonRavitz, they help you as a doctor safeguard your most valuable asset, your income, so you can protect the most important people in your life, your family. PearsonRavitz makes human connections before they make quotes. Go to pearsonravitz.com today to schedule your consultation with a PearsonRavitz advisor.
Dr. Jim Dahle:
All right. Don't forget about all the stuff we have going on here. We're trying to recruit people to speak at the next WCICON down in Phoenix. You can apply for that at www.wcievents.com. Today's actually the last day when this is dropping. So, if you haven't signed up for that, I hope you feel a little bit of urgency here.
Dr. Jim Dahle:
Watch the blog for the next few days. We're going to have a course sale. We'll have all the details on the blog. We're recording this a few weeks in advance, so we don't have them all worked out as I record this, but this is kind of at the start of the medical year. We often have a course sale for our online courses. So, watch for that.
Dr. Jim Dahle:
Thanks for those of you who are leaving us five-star reviews and telling your friends about the podcast. That really helps spread the word about it and help other doctors to become financially literate. Our most recent one said this, “Play this in your home while your spouse is around, it's more effective than having a talk.”
Dr. Disha Spath:
So true.
Dr. Jim Dahle:
They say, “I sailed through all five available episodes yesterday between a workout and a closet cleaning. Dahle is relevant, entertaining, and blessedly both irritated”. Irritated? I'm not sure if that's what they meant to put, but that's what they put, “Both irritated and knowledgeable regarding the same specifically medical grips we have in finances. He shows obvious effort to be trustworthy and thorough and provide insight for the continuum between more conservative and more lavish financial lifestyle choices while still staying in the realm of prudent.”
Dr. Disha Spath:
Wow.
Dr. Jim Dahle:
“His pace is perfect for non-financial smart folks. I was also delighted with my new ability to sneak in a financial discussion simply by playing this podcast during the closet clean-out. My husband magically stopped reading his book and then commenting on topics he has a history of avoiding. I must try this while driving with him.” That's from J. S. Hinton, five stars. I appreciate that review. That's nice of you to say that.
Dr. Jim Dahle:
Well, our time has come to an end. It's been wonderful doing this with you as always, Dr. Spath. For the rest of you out there, keep your head up, shoulders back, you got this and we can help.
Dr. Disha Spath:
You got this and we can help. Together.
Dr. Jim Dahle:
Absolutely.
Dr. Disha Spath:
Bye all.
Disclaimer:
The hosts of the White Coat Investor podcast are not licensed accountants, attorneys, or financial advisors. This podcast is for your entertainment and information only. It should not be considered professional or personalized financial advice. You should consult the appropriate professional for specific advice relating to your situation.
Thanks for addressing this topic. A few reflections of mine as a male MD who went through multiple rounds of IVF with my spouse during fellowship/attending years:
1. The psychological toll of infertility is not confined to women alone (unlike the physical toll). My fellowship years are permanently tainted with the lonely struggle of infertility while living in a hospital-owned building for residents/fellows that was teeming with children. There was a persistent malaise that fell across our household that no amount of restaurants or travel could alleviate. Many people said very hurtful things, most of them unintentionally but sometimes with ignorant sincerity (all the talking about timing out pregnancy as if it were an exercise regimen, the questions at my synagogue about when we would have kids, “just relax”, “you’re lucky you don’t have kids and can do X”). Ultimately, only people who have really gone through this can understand the spiritual/psychological burden (the reddit forum r/infertility ended up being the most helpful). So when it comes to wellness/mental health, this is an issue for a much larger percentage of doctors/professionals. It can also deeply affect marriages, which affects your job performance as well.
2. The finances can be much more stressful depending on your situation as well as insurance. This was less of an issue as an attending but it’s harder as a student or resident. A significant additional cost may be that of travel if you are not near an RE clinic (or if you need to travel to a more reputable one that has more experience for your condition).
3. Most cycles of IUI/IVF do NOT work. This is all the more true as you get older. For our first child we we went through four cycles of IUI and one of IVF when my wife was 28-29 years old. For our second child, we went through 4 IVF cycles and my wife was 32-33 years old at the time. Success rates decline dramatically after age 37 or so. You have to pay for each cycle up front – so the costs go up quickly but the assurance of “success” does not. You can end up with a big bill and no baby (couples who have gone through this process without success are rarely featured on podcasts/articles about infertility).
4. I thank G-d for the children we had in the end, even when they drive me crazy. I agree with the doctors that there are some things that matter much more than saving for retirement, and if you want to have and raise children, this is clearly one of them.
Thank you for sharing your perspective. I think the spouse’s experience can often be overlooked.
Thanks for this thoughtful comment. I’m definitely with you on the (often unintentional) hurtful commentary; my presentation on this topic at WCICON22 had a whole section dedicated to “what not to say” and “what to say instead” to support people going through infertility. And you are completely correct. This is not just a woman’s issue physically and psychologically.
Thank you for bringing up the important point of the whole family’s experience through fertility treatments.
Thank you for sharing your stories and for raising awareness on so many aspects of this, both infertility and career/ pregnancy timing. Warning- TMI?/ As a new grandmother I find myself jealous of/ happy for my hard won child. Even at a somewhat younger age (well, 29) I had athlete’s triad as a soldier doctor and between our call schedules and fatigue was quite lucky to conceive one of the two times I ovulated that year*, and quite smart to be charting to make sure we caught those times. Then was 6 weeks of maternity leave, an insistence that I return to work for the 3 weeks before we PCSed despite having leave saved up (a prior resident leaving the military with postpartum depression might be the reason they did that to me, or maybe her illness was worsened by the climate of that organization), and even a request that I come back to work during my maternity leave while my husband and other residents were off at a conference. (That attitude also probably discouraged me from remaining in the military.) Now that kid has 12 weeks of maternity leave, the ability to work from home and part time for an extended period of time using both her maternity and regular leave spread out, and this retired grandmother as a part-time nanny. (She and her friends have also all extensively discussed pregnancy timing / infertility and in my doctor mindset are overly worried about infertility.)
*I like to tell the story that, as per protocol, the medical assistant asked me my LMP. I said I am about 10 weeks pregnant, I ovulated 8 weeks ago. They again asked for my LMP and I told them 11 months ago. They decided to go by the ultrasound.
It’s sad that we delay childbirth, then try to get pregnant at 30, have problems, then wonder why it didn’t work.
Our society is sick. It we really cared about family formation, we would marry women off at 18 instead of sending them to college. I mean, I guess you need to go to college if you’re going to become a doctor- but delaying childbirth so you can get a sociology degree and work as a secretary for a few years? Before maxing out your credit card for IVF?
This whole blog seems to have people who don’t like actually being a doctor- and want to FIRE. Or they become real estate investors. Maybe we need to reform medical school admissions to be mostly male again. And select for people who actually want to be doctors; not real estate professional status AirbNB HOOM hoarders levering up with their fifth bRRRR.
It’s not politically correct. People thought I was insane for getting married and having a kid in college. Now they are having breakdowns at work because their third round of IVF failed. Maybe feminism was a lie?
This should be a controversial comment.
This comment IS controversial. An alternative to banning women from medical school, or forcing them to get married at 18, is, if we really value children and especially if we really value children of women likely to become college graduates and professionals, we should enact legislation to provide better support for people to have children and to continue their education and professional employment while they do so. A lot of European countries do it that way. But we have so much immigration and still don’t really value children and have a ‘pull yourself up by your own bootstraps like I did’ mentality which ignores how many of the successful people started on second or third base instead of having to fight for a chance at bat. I’m hoping as women become more vocal and have a stronger role in politics that we will try to take care of other women, but then I read a comment like this and doubt it.
You are allowed to have this perspective, just as I should be free to pursue medicine as a woman and balance my work and family on my own terms. There are tradeoffs with everything. I wish I had known sooner that I actually wanted to have children, but I’m grateful that I have choices on both sides. The problem comes with trying to fit everyone into the same box. As much as people think the contrary, we still live in a country of choice.
I guess we will have to respectfully agree to disagree.
Medical education, and medicine itself is subsidized in this country. Maybe not like the NHS, but it still is. I think it’s immoral to subsidize a system that promotes pumping 16 year old girls with Progesterone, and then later having 35 year old women doing IVF. (I think IVF is wrong for anybody.) My Senator just had an IVF baby at 50. Will she even be alive for the high school graduation? I now know more people who’ve had children via IVF rather than the old fashioned way- getting drunk on vacation. Maybe just going on vacation for our LDS friends :-). Many of my friends are pregnant now while my kids are in college.
I still regret those years I spent pursuing a career rather than making my baby the priority. I was lied to about the idea that I can have it all. I’m just being honest about my mistakes. I hope other people find peace with theirs.
It’s just absolutely insane. This is not a serious way to run a society. Why is nobody talking about what’s best for the children? It’s just me, me, me, my career, my rights, my causes, me, me, my freedoms, me, me, my choice, me, me.
Wirehouse FA here. Thank you for bringing attention to this often overlooked topic. My wife and I got married at 22 and 20 respectively. We had our first 2 kids within 4 years of getting married, and she got her degree online during that time! Financially speaking, it was a terrible move. Think about the TVM/compounding all the money we spent having them and raising them! But practically speaking, it was the best move ever. My wife and I decided that raising and enjoying a family was far more important than the balances in our brokerage accounts. Unfortunately many only come to this realization much later on in life.
Just a reminder here that age is not the only reason to pursue IVF. There’s other causes of infertility that are not age related. Infertility is a disease, and wanting to treat that disease is normal. Reproduction is deeply personal and should remain an individual decision. Being a doctor makes me a better mom and vice versa. What’s right for you and your family doesn’t dictate others choices.
Completely agree with this. Yes, age was a factor in my journey, but I experienced an organic cause of permanent infertility that had nothing to do with how old I was. I discuss this in the podcast interview, as well as my thoughts on why infertility has become more common over the years. In addition, a third of infertility cases involve a male factor cause, so this cannot be lumped in with maternal age.
Infertility is a medical diagnosis and should be treated as such – especially in a physician workplace or community.
Absolutely agree with this.
Via email:
Jim – podcast #269 was a good one. But there are other (much cheaper) ways to navigate infertility not mentioned in the podcast. An organization in TN facilitates embryo adoption (https://www.embryodonation.org), and if you are willing to take a special consideration embryo (e.g., bio mom has Hep C) it can be free of charge for the IVF cycle. Additionally, we have done foster care for many years (starting in fellowship) and in that case the state will pay for you to care for these kids that need a family. Just want to get the word out that there are other non-traditional ways to build a family
Thank you for sharing these resources and thank you for bringing up fostering!
Thanks for this reminder. I’m hearing more and more of physicians using embryo adoption.
Our medical education and training system needs to be changed from the ground up. This advice is good for people whose fertility is on the wane already, but really “primary prevention” needs to start earlier on.
When I became pregnant during fellowship I recall not being able to get into the OB clinic on main campus because they “weren’t taking new patients,” but there were ads all over the resident’s lounge offering urgent on-campus appointments to get in for contraception.
We waste a lot of our precious fertility years in unnecessarily prolonged 12 year grade school programs (which could be completed in a much shorter span). In many countries there is no 4 year undergraduate requirement and it is quite normal to start medical school at 18. Our education system needs an upheaval. I’d encourage people to read “ The brainy bunch” about a family who got all their kids into college at 12.
As I tell any resident who asks for my advice: there is never a “good” time to have a baby. Any hospital or training program/organization will want the most work out of you, paying you as little as they possibly can. Pregnancy and maternity leave, therefore, are undesired in the work force. They do not care if you reach your 40s and are miserable because you have no kids. So why should you be a sacrificial animal for the system? Start trying to conceive on time. Once you have your baby, the system and your life will be forced to accommodate, and you and your bank account will be grateful later.
You do need to have a good support system. It takes a village to raise a doctor momma. My father advised that I not marry another doctor but rather marry someone with a much lighter schedule so that he would have time for the kids, because I A’s a doctor would not, he was right, and I’m so glad I took his advice.
Thanks for this comment. There are a lot of problems with the education and training system in this country, and with the rise of infertility we are really seeing some of the manifestations. In the meantime, I advocate for forging your own path to work-life-family balance regardless of what is “expected” or what others in this space are doing. This is where financial literacy comes in as well. Keeping priorities in mind as you start your medical career is KEY.