For the emergency physician navigating infertility or pregnancy loss, the inherent stresses of a demanding career are compounded by a physical environment that is uniquely unforgiving. The emergency department rarely offers a predictable schedule, little protected downtime, and no “light duty” even when external factors may demand one. 

Female physicians already experience significantly higher rates of infertility and pregnancy complications compared to the general population. A survey of 4,533 female physicians found that compared to the general population, female physicians were older at first pregnancy, more often underwent infertility evaluation and treatment, and had higher rates of miscarriage and preterm birth [1]. Among female physicians surveyed, 36.8% reported a personal history of infertility, with more than half requiring in vitro fertilization (IVF) to conceive, which is substantially higher than the 6-19% infertility rate in the general U.S. population [2]. A 2024 systematic review similarly identified that approximately one in four female physicians is affected by infertility, with female physicians reporting IVF utilization rates as high as 76%, which far exceeds the general population [3].

Physicians delay childbearing relative to nonphysicians, with only 2% having children before completing medical school and mean age at first birth of 32 years compared to 27 years for nonphysicians. This pregnancy delay places physicians into advanced maternal ages, when risks of infertility and adverse maternal and fetal outcomes are more pronounced [4]. For emergency physicians specifically, these risks are further amplified by the structural realities of shift work, including overnights, and a culture that has historically ignored pregnancy as a medical condition warranting accommodation.

A systematic review and meta-analysis of 62 observational studies involving 196,989 women found that working fixed night shifts was associated with increased odds of miscarriage [5]. Night shift work demonstrated a dose-response relationship with early spontaneous pregnancy loss. Women working two or more night shifts per week have a 32% increased risk of miscarriage after pregnancy week 8 [6]. A separate prospective cohort study of 22,744 Danish hospital workers corroborated this finding, and also noted that women who worked 26 or more night shifts between weeks 4 and 22 of pregnancy were more than twice as likely to miscarry [6]. A  meta-analysis specifically examining shift work found that night shifts were associated with an increased risk of early spontaneous pregnancy loss [7].  The American College of Obstetricians and Gynecologists acknowledges that night shift work appears to confer a slight to modest increased risk of miscarriage, though more research is needed in the area [8]. Night shift work has also been linked to hormonal disruption, irregular menstruation, and failed embryo implantation - mechanisms mediated by circadian rhythm disruption and suppression of melatonin, which plays a critical role in placental function and early pregnancy maintenance [9]. Miscarriage is prevalent among female emergency medicine physicians, and just as prevalent are stories of women working shifts while actively miscarrying or immediately after. The culture of Emergency Medicine that causes women to work while suffering a miscarriage fails to acknowledge the profound grief and long term psychological effects associated with early pregnancy loss [10].

The psychological consequences of pregnancy loss are substantial and frequently underestimated. Between 25-50% of women who experience early pregnancy loss develop clinically significant negative mental health responses, including depression, anxiety, and post-traumatic stress disorder (PTSD). A 2017 meta-analysis found that the prevalence of complicated grief following perinatal loss was nearly three times higher than after other types of loss [10]. These effects are not limited to the birth parent: research shows that 66.3% of male partners of women experiencing recurrent pregnancy loss also show signs of anxiety, and 19% meet criteria for depression [11]. Emergency physicians - who are already at elevated risk for burnout and psychological distress - face this grief in an environment that historically provides no space for it.

IVF is a multi-step process in which eggs are retrieved from the ovaries, fertilized with sperm in a laboratory, and the resulting embryo is transferred to the uterus. The process unfolds over weeks to months and requires time-sensitive monitoring appointments, hormone injections, and procedures that often cannot be rescheduled. The nature of IVF monitoring and procedures are difficult to reconcile with the mandate of emergency medicine. Short sleep duration and shift/night work schedules may all adversely affect female fertility and IVF outcomes, including by reducing the number of mature oocytes retrieved and lowering clinical pregnancy rates, so anticipatory support is crucial for physicians undergoing the procedure [12, 13]. A 2022 prospective cohort study found that women working evening, night, or rotating shifts had on average 2.3 fewer mature oocytes retrieved than day-shift workers, and poor sleep quality has been independently associated with a 50% reduction in IVF success rates [14].

It is also important to recognize the toll of IVF on partners. The emotional and logistical toll of IVF cycles and the psychological impact of pregnancy loss affect both partners, regardless of who is physically carrying the pregnancy. Research demonstrates that partner support is critical during fertility treatment, with men's infertility stress associated with their partners' low levels of partner support [15]. Finally it should be noted that IVF carries large financial costs, often tens of thousands of dollars per cycle, and is frequently not covered by employer-sponsored insurance plans. Proactive institutional advocacy for comprehensive fertility benefits is therefore both a retention and an equity issue [3].