The high cost of physician infertility

Rebekah Bernard, MD

In 2023, the Medical Student Section of the Florida Medical Association (FMA) submitted a resolution asking for recognition of the issue of physician infertility and more education on the topic. In response, the FMA hosted a webinar with experts on various aspects of physician fertility. This is part 3 in a series based on that webinar.

Women physicians face a 25% chance of infertility, a much higher rate than the average American couple. While infertility can take a psychological toll, it also carries a sizeable financial cost. In-vitro fertilization (IVF) costs range from $15,000 to $30,000 per cycle, averaging $40,000 per successful in-vitro fertilization outcome using a woman’s own egg and $73,000 with a donor egg. Gestational carrier (or surrogate) pregnancies are even more expensive, starting at about $130,000. Adopting an infant is also expensive, estimated at $20,000 to 45,000 for a domestic adoption, and sometimes more for international adoptions. While fostering to adopt is less financially expensive, there may be additional emotional costs to consider.

Pediatrician Sarah Marsicek, MD has experienced the financial and emotional costs of fertility treatments and adoption firsthand. “I’m from the Midwest, and our culture is to have babies young,” said Marsicek, who met her husband in medical school and wanted to start her family right away. “Because I was treated for Hodgkin’s lymphoma when I was younger, I was afraid that fertility would be an issue.”

While her first pregnancy resulted in miscarriage, Marsicek became pregnant again during her intern year. This pregnancy was complicated by pre-eclampsia which started while Marsicek was rotating through the inpatient unit. “I did my blood pressure checks right after rounds,” she said, noting the conflict between work responsibilities and her health. “I went in for labs and they had to admit me—I remember saying, ‘You don’t understand, I have to be at work tomorrow morning.’” After her son was born, Marsicek recalls walking down to the resident work room, IV pole in tow, to gather her belongings. “You’re not supposed to do that, but I wanted to clear the space for the next resident,” she said.

Despite the difficulty with her first pregnancy, Marsicek and her husband decided to start trying for baby number two. “It seemed like everyone wanted to know, ‘When’s the next one coming?’” said Marsicek. This time, conceiving wasn’t easy. “We spent a year trying, and then realized that we needed to consult with a fertility specialist,” said Marsicek. Still in her fellowship training, she said that seeing the prices for fertility treatment gave her sticker shock. “We definitely couldn’t afford treatments at this juncture in our lives, so we started looking at other options,” said Marsicek. Researching adoption, she learned that the costs were even higher than IVF treatments. Instead, the couple decided to pursue foster care.

Foster care

“We became foster parents for two years, which was great, but incredibly frustrating,” said pediatrician Sarah Marsicek. “It’s a very broken system and a thankless job in that your life is not yours anymore—you are at the beck and call of the state at any time.” Marsicek and her husband hosted several children temporarily as their parents worked to regain custody. At the start of the COVID-19 pandemic, they were presented with a baby who was eligible for adoption. “The social worker dropped him off at 10:30 at night and told us that since he had five siblings adopted out of foster care, he was going to be with us forever.”

Marsicek was ecstatic over the next four months, as it seemed adoption was in sight. “And then one day, we got a call that the state was going to pick up the baby because a distant relative wanted him,” she said. “I will never forget the screams of him being taken from the house and put into the social worker’s car. It still haunts us.”In addition, the couple’s four-year-old son started to develop behavioral issues after the experience.

Intrauterine insemination (IUI)

Traumatized by the foster system, Marsicek and her husband decided to take a break. “It was just too much,” she said, “I decided to leave my fellowship a year early and get a job as an attending pediatrician,” she said, in part because the higher salary would allow her to pursue fertility treatments. After consulting with her physician, Marsicek elected intrauterine insemination (IUI) over IVF.“We spent tens of thousands of dollars, and on the fifth attempt, I asked my doctor, ‘Is this ever going to work?’ and he said, ‘No.” Marsicek said she was shocked. “I asked him, ‘Well, why are we doing this?’ and he said, ‘Because I’m waiting for you to say that you want to do IVF.’”

At this point, Marsicek and her husband felt stuck. “We had a long conversation about what it means to be a parent, and whether we could be good enough with just one baby,” she said. “We had always talked about adoption, even back when we were dating because I always knew there was a chance I wouldn't be able to have kids, and we felt very fortunate that we had our son, who was one of those unexplained miracles.”

Adoption #1

Marsicek and her husband decided to pursue private adoption. “We had saved up quite a bit of money, so we signed up on waiting lists with four different adoption agencies,” she said. They matched with a mother who they got to know through letters and video calls. “She was very committed to the adoption, as were we,” said Marsicek. But at 34 weeks of pregnancy, the mother experienced a placental abruption and lost the baby. “My husband and I were devastated. I just started sobbing uncontrollably,” said Marsicek. “I wondered if we were just not meant to be parents again.”

But the couple started the process of matching again. “We got a call for a little boy that was due in a month,” Marsicek said. As they were reviewing the contract, the phone rang. “They said, ‘Hey, you need to get to Arizona. The baby was born.”Marsicek and her husband traveled to meet their new baby. “He was premature and very small, as well as going through drug withdrawal,” she said. The baby’s birth parents signed the termination of parental rights, and after a 13-day neonatal intensive care stay, the Marsiceks’ new son was released to go home. Despite his early ordeal, their son did well. “He’s now three years old and quite the handful—very rambunctious!” laughed Marsicek.

Adoption #2

With two boys at home, the Marsiceks still hoped for a girl. Since the first adoption process had taken so long, they decided to start the process right away. This time, they matched with a birth mother quickly, but at the last minute, the adoption failed, and in addition to the disappointment, they lost their financial investment. “They tell you that adoption costs $40,000, but they don’t tell you that a child isn’t guaranteed,” said Marsicek.

But the Marsiceks’ adoption journey wasn’t over yet: An adoption agent called with surprising news. “She said, ‘I don’t know how to tell you this, but I think I found you a daughter,’” said Marsicek. The agent told Marsicek that this was the mother’s first pregnancy in which she was considering adoption, and she was quite anxious about the process. “She told me that when she met this mom, all she could think about was us,” said Marsicek. “She said, ‘I hope it’s ok that I told her all about you, and she really wants to match with you guys, if you’re ok with that.’”

Indeed, they were, and the Marsiceks’ daughter was born on December 20th.Despite drug withdrawal, she was home in time for Christmas. “She was our best Christmas gift,” said Marsicek. Now eighteen months old, their daughter is healthy and active.

Paying for fertility

“Our last two children cost us $165,000 and that doesn't include all the fertility stuff that we went through,” said Sarah Marsicek. “It was a really expensive, very time-consuming process, and you don't realize how deep you’re going to get in the hole financially.”This was a particular challenge as Marsicek provided the primary family income in the lower-paying specialty of academic pediatrics. “It was really scary financially, and we ended up having to take a home equity line of credit to pay adoption expenses,” she said, supplemented by loans from the couples’ parents.

Adding to the financial stress, Marsicek transitioned to part-time work for a year to spend more time with her young family. “I call it my healing year because after that time off, I fell in love with medicine again,” she said. She gradually increased her academic work hours and supplemented her income through locum shifts to offset expenses. Marsicek recently resumed full-time practice, noting, “I expect to be much more financially comfortable soon.”

Adoption and the opioid crisis

Sarah Marsicek’s adopted children faced adversity in utero, including drug exposure. “My second son had no prenatal care and was born prematurely in the hallway of the hospital,” said Marsicek. “He suffered a perinatal stroke, so he was slower to walk and required intensive physical and speech therapy, but he is as smart as a whip and has beat all of our expectations.”

Although exposed to drugs, Marsicek’s daughter had excellent prenatal care and was born at full term. “She hasn’t shown any delays so far,” said Marsicek, who wants to destigmatize adopting opioid-exposed children. “There’s a lot of fear about adopting children that have been exposed. Obviously you can't control what happens before they get to you,” she said. “You just pray that it's all going to work out, and really it has for us.”

The importance of flexibility and support

After experiencing pregnancy and childbirth during training and fertility treatments, fostering, and adoption as an attending physician, Sarah Marsicek can speak to the importance of support for women physicians. “Fertility treatments are so time-based, and it was impossible to schedule appointments,” she said. “I would get the earliest appointment I could, leave work for an hour or so, and then come back to work.” Despite her best effort to minimize time away from work, she felt pressure from her employers. “There were a lot of comments like, ‘Oh, you’re leaving again,’” she said. “I think this was one of the reasons that I decided not to pursue IVF.”

In addition to work support, women physicians need strong personal support. “This is not a journey that anyone should go on without support—having a partner that is 100% with you on all these decisions, or for those without a partner, having support in some way,” said Marsicek, who said that she is fortunate that her husband works from home. “This is how we can have three children with my schedule. When I’m not home, he steps up and does all the drop offs and pickups.”

Overall, the most important lesson Marsicek has learned is to be flexible. “Life doesn’t work out the way you want it to most of the time, but don’t give up. If you’re willing to pivot, you can still make your dreams come true.”

Rebekah Bernard, MD is a family physician in Fort Myers, FL and the author of four books, most recently Imposter Doctors: Patients at Risk.