Pregnancy, parenthood, and fertility in the orthopaedic surgeon

Listen to Andrew Duckworth, Catrin Morgan and Lily Li discuss the paper 'Pregnancy, parenthood, and fertility in the orthopaedic surgeon' published in the August 2023 issue of The Bone & Joint Journal.

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Transcript

[00:00:00] Welcome everyone to our BJJ podcast. I'm Andrew Duckworth and a warm welcome back to you all from your team here at the Bone and Joint Journal. We hope you're all having some well earned ti time off with family and friends during the summer period. As always, we'd like to start by thanking all of you for your continued comments and support, as well as our big thanks to our many authors, authors, and colleagues who have taken part in our series.

Our podcasts continue to focus on papers published here each month here at the BJJ, as well as our accompanying special edition podcasts throughout the year. So today I have the pleasure of firstly welcoming Catrin Morgan, who is an orthopaedic registrar from Imperial to discuss their paper entitled 'Pregnancy, parenthood and fertility in the orthopaedic surgeon: a systematic review', which has been published in this month's edition of the BJJ.

Welcome, Catrin. It's great to have you joining us today. Oh, thank you so much for inviting me. Joining Catrin is a colleague and senior co-author Lily, who is a consultant orthopaedic surgeon, also at Imperial Lily, thank you so much for taking the time to join us. It's great to have you with us. Thank you so much for inviting me.

Pleasure to be here. Great. So I, I'll, I think we should get right onto the [00:01:00] paper both. Cause I think it's, it's such a, an important topic and there's lots that to, to, to discuss both in the findings and the implications of it as well. And your study highlights such an important area in our specialty, particularly given the very positive trends we're seeing in an increasing number of female surgeons choosing a career in orthopaedics.

And given this as you highlight it, is therefore really important to recognize and understand the common themes and data surrounding pregnancy, parenthood, and fertility within our specialty. So, Catrin, if I could maybe start with yourself as a background to study for our listeners. Can you give us a brief overview of the state of the current literature on this topic and what caused you to look at it at this particular question?

So, as you mentioned, where whilst considered a traditionally a male specialty T&O is definitely becoming increasingly diverse with 15 to 26% of doctors in the UK, USA and Canadian orthopaedic training schemes being women. In 2020, Todd et al published a systematic review looking at surgical residents across all surgical specialties.

And this review included [00:02:00] 27 studies and found that female surgeons experienced high rate of infertility, obstetric complications, and they also contend with negative attitudes and stigma during their pregnancies, and alongside with voluntarily delaying childbearing. And since the publication of this review, there's been a few additional papers published specifically in the field of orthopaedics related to this topic. In terms of why we chose the topic.

So as a female orthopaedic trainee myself, I've often been given advice on when the correct time to have children would be for my career. And often that advice is varied and most people do say delay until after your exam, for example. Mm-hmm. I think there is never gonna be a perfect time to have a child, and everyone's circumstances are different.

However, I think it is really important before making a decision to delay childbearing, to look at what the literature shows and to learn from other female orthopaedic surgeons who have gone through pregnancy and parenthood. I think that's very well [00:03:00] put Catrin, like you say, it's, I think that's why it really, it jumped out to me

did your paper. I think that the information it provides and the data it provides is, is really interesting and I think, like you say, to help you make a, a more informed decision, I suppose, like you say. So with this, this, this in mind Lily, if I maybe come to you next, what were the key areas you wanted to look at as part of the, of the systematic review?

What were the sort of aims of it? Yeah, so the aims of our study were to, to firstly look for common themes. And data out there surrounding pregnancies, surrounding parenthood and fertility, particularly relevant for orthopaedics, not just surgery in general. And we wanted to look at whether female orthopods delay childbearing either during their training or after, have high rates of obstetric complications and infertility and see if we could find any barriers

to getting pregnant and having and being a parent. We, we hope that the, the findings of this review helps to inform other [00:04:00] orthopaedic female orthopaedic surgeons who are making these pretty difficult decisions regarding pregnancy and also helping to raise awareness so that we can create a supportive culture for the pregnant orthopaedic surgeon.

Absolutely. And I think that with the publication of your paper, I think that's what it, what it does. I think it really raises that awareness as you, as you say, and, and for everybody within our specialty. So, so moving on to the methods, which I'm, I'm just gonna touch on briefly because there's, there's a lot more interesting things to talk about about the paper in terms of the findings and, and, and the implications of that.

But if we move on to the study design briefly, this was a systematic review conducted in line with PRISMA guidance as we'd expect, and it aimed to maximize the objectivity of the area while also ensuring sound methods were used throughout, throughout the study. So Catrin, very briefly, if you could just give us an overview of the eligibility criteria you used for the studies that you included.

Yeah. So we required the studies to meet a few different inclusion criteria. So they must examine pregnancy and parenthood and or barriers to [00:05:00] it. They must involve surgeons at any stage of their career who had specialized in trauma and orthopaedics. They must be in English, and they had to be original research as classified by the Oxford Centre for Evidence-Based M edicine.

Due to the heterogeneity of the studies included in the review, we didn't feel it was appropriate to perform a meta analysis. Absolutely. And, and I think when you look at the data that, that makes a, a lot of sense. And in terms of what data was extracted from, from these studies. So we extracted the lead author's name, the year of publication, country of study participants, the design of the study, the study participants themselves, and the sample size.

And then we also recorded the key findings and identified the main themes within the studies. Perfect. Yeah, grand. And I think, like I said, I think we'll move on to the results as well, cause you, you detail the methods very nicely in the paper and our readers can obviously go to that if they need to. So, cause I'm quite keen to move on to the results and, and and what they mean.

And so if you move on to what you found, you had a total of just over [00:06:00] 1200 papers identified from your initial search and after you removed duplicates, you just have had just over 770 were assessed for eligibility of which 19 met the criteria and were included in the review. So, Catrin, if I could just ask you, what did you find in terms of just the general makeup of the studies that you included?

Yeah, so out of the 19 studies, 11 of them were female orthopaedic surgeon respondents only four included both male and female orthopaedic surgeons, and this was a total of 4,327 survey responses of which 300,394 female and 993 male, and out of the remaining four studies. Two were analyses of training programmes and two were responses from training programme directors.

The common themes we identified were obstetric complications and congenital abnormalities, fertility, occupational hazards, and barriers to pregnancy and parenthood. And I think those, those four, four themes really come out in, in the pap, in the [00:07:00] in, in the study. And I think it, they really break it down very nicely, I think, in terms of what we're gonna discuss now.

So if we sort of take the first one, what did you find in terms of the rate of obstetric complications and congenital abnormalities in orthopaedic surgeons? So the rate of obstetric complications was noted to range from 24 to 31% which was higher in comparison to the general population, which was around 14%.

And the rate of congenital abnormalities was reported in three studies, and this is in the orthopaedic surgeons offspring and ranged from six to 7%. And this call was compared to one to 3% in the general population. And a study by Hamilton et al, which was published in the JBJS American reported preterm labour resulting in either a pre-term or term delivery as the most common complication.

And they also noted an increased risk of preterm labour in respondents who bought work more than 60 hours per week. I think that's [00:08:00] really interesting findings. I thought those, that they were really striking when I read them. And you know, when you look at those numbers compared to the general population, it's, it's almost double, isn't it really that if you take the, the extremes of those, those ranges, it's, it's quite, it's quite stark.

And, and what about in relation to fertility rates? Yes. So a number of papers reported infertility in the orthopaedic surgeon and rates were ranging from 18 to 32%. The women who reported infertility had their first and second chi child at a later stage in their career compared to those who didn't.

And one study reported this rate to be comparable to an aged matched control population suggesting that the main reason for infertility or the difference is due to older age. The age at birth of the first child in the female orthopaedic surgeon ranged from 33 to 34 years, and a study by Ponzio et al reported an average age of 34 years in the female surgeon compared to [00:09:00] 31 in the male orthopaedic surgeon.

I think again, I thought that was really interesting. And like you say, it's, it's this, the, the, the, the maternal age, isn't it? Which we know is a risk factor anyway. But it's actually, that's why I think the study, the, the study on your paper goes on very nicely to sort of explore why, why that delay is potentially a occurring.

So li if it, Lily, if I could maybe come back to you please. As part of the study you looked at potential occupational ha hazards, which I thought was really interesting to the, to the pregnant or lactating orthopaedic surgeon. And what did you find with regards to this? Yeah, so there are several potential occupational hazards including exposure to PMMA, which is bone cement.

Mm-hmm. General MSK injury, as well as ionizing radiation risk. One of the surveys we found where they surveyed orthopaedic surgeons and they reported that 38% scrubbed out during the cementing phase of an arthroplasty operation when they were pregnant. Mm-hmm. And 16% scrubbed out whilst they were breastfeeding during the cementing phase.

And another study by [00:10:00] Linehan looked at the presence of PMMA in either serum or breast milk, which had been collected from two surgeons who were lactating after they'd been exposed to PMMA during eight arthroplasty procedures. And then that was, those levels were compared to two healthy breastfeeding women who didn't have any PMMA exposure.

But interestingly, they found that PMMA was actually not detectable. At the 0.5 part per million, which is a significant level in either serum or breast milk. Another study that we found, which is Zadeh et al, and they reported a higher rate of congenital abnormalities in both male and female orthopaedic surgeons.

However, they compared to a group of age matched obstetricians and gynecologists, and they were then further divided into two subgroups based on how much routine x-ray exposure those groups had. And again, they didn't actually find any statistical difference in the rate of congenital abnormalities across all these groups.

And so the author suggested that actually the [00:11:00] increased rate was likely to be associated with factors other than exposure to ionizing radiation. Yeah, I thought that that was interesting, wasn't it? And, and yeah, in some ways potentially reassuring, but I it is limited data, isn't it? But you just yes, it was, it, it was interesting that I thought, cause it is, it's probably, it was maybe a misconception I had cause I would've assumed that the opposite of what, of what they showed.

And, and so moving on from that, Lily, and I think this is one of the really interesting, I mean that's all very interesting, but I think a really interesting bit is when you looked at the, you, what you found in terms of the barriers. To identify to pregnancy and child bearing within orthopaedics. Cause I think this really highlights some important issues and, and I suppose as well what we can read you something about in many ways.

Yeah. So so we'd found that between half and two thirds of, of female orthopaedic surgeons reported voluntarily delaying child bearing during their training. And the reasons that they gave for doing so was missing training time or financial [00:12:00] constraints, time limitations, and missing out on quality time with, with their family.

And in one of the studies published by Mulcahey et al out of 92 respondents who reported deferring childbearing, 20% reported that actually to, to them the most important reason was to, was to prevent a negative perception by their male colleagues or faculty members. Three other papers we found, explored what training programme directors, so TPD perceptions of pregnancy were.

And this included several responses from 143 of them from American accredited training programmes. And those studies found that pregnancy and parenthood did pose a burden on, on the fellow orthopaedic trainee and affected their educational time. And one of the other studies by Nemeth demonstrated that TBDs themselves, perceived the effects of pregnancy and child and parenthood more negatively for their female trainees to a very statistically significant extent.

But [00:13:00] however, interestingly, that difference was perceived more by male programme directors, whereas female programme directors actually felt they had no effect. And one other barrier that we, we found for the female orthopaedic surgeon was returning to work and facilities for either breastfeeding or breast pumping whilst at the workplace.

And prior to very recently, the introduction of some regulations, there was actually. A lack of an, an uncertainty whether any formal breastfeeding policies even existed. Yeah. And surgeons who actually discontinued breastfeeding before six months. So early. Discontinuing reported problems with accessibility, who breastfeeding and time allocated for breastfeeding after they're return to work.

I think that, I think that's, that's really interesting. I think just the way the, the list of things there, you know, which have, like you say, it, it all flows on very nicely in terms of, in this, in the paper, I think in terms of the issues that are there, in terms of the numbers and then the reasons, potential [00:14:00] reasons why that that is, and how those potentially need to be addressed or, and, and, and like, like you've already alluded to, have been addressed in some way with, with recent regulations.

So I think maybe that really nicely moves us onto sort of putting it all into context. I think, you know, In terms of the study itself, I think the strengths and, and the importance of it are, you know, in my mind or without question, I'm sure many of our reading this still feel the same. You know, it's, it's a large systematic review that has examined the common themes and data surrounding pregnancy, parenthood, infertility within orthopaedics.

Such an important topic. And it, and it clearly, I, I think it clearly demonstrates that female orthopaedic surgeons voluntarily delay childbearing and suffer higher reports of rates of infertility, obstetric complications, and congenital abnormalities, and also highlights that they bear children at a later age compared to the general population.

And certainly from the data, it seems there is a negative stigma and perceptions associated with pregnancy and orthopaedics, which can lead to our colleagues voluntarily delaying childbearing, which has those knock on effects, which we've alluded to. So, Lily, what, you know, what do you feel are the, for you, what, what do you [00:15:00] feel are the key findings of the study and how should, and I suppose as well, how the data can be attributed in the context of any limitations that, that are there with that data.

Sure. So as you, as you mentioned, Andrew, the key findings are that female orthos have high reported rates of obstetric complicit abnormalities. Infertility. We have children at a later age and we voluntarily delay this. And the negative perception of pregnancy from our fellow trainees and TBDs and colleagues do appear to be contributing in part to this delay.

Mm-hmm. And there are definitely limitations to our study. And firstly, all of the studies are cross-sectional studies with retrospective data collection, which obviously can lead to recall bias and reduces the accuracy compared with anything that's prospectivity collected. Also about half of the studies consisted of respondents from American training programmes only, and obviously some aspects of the American system are not necessarily applicable to other healthcare systems, not just the UK [00:16:00] system.

Mm-hmm. However, we believe that actually important themes are transferable. A further eight of the studies that we included were classified as international because the participants were from orthopedic societies with an international membership. However, they don't actually break down the, the contrary specification in any of these.

Mm-hmm. Yeah. And another limitation is that the controls used in the studies are not the same. They're not constant, and they can be varied from the general population to male orthopaedic surgeons to non-orthopaedic, but female surgeons. And so this made it quite difficult to make any direct comparisons between the studies and, and as Catrin mentioned, we weren't then able to carry out any numerical analysis.

Yeah. And it's also sort of lastly important to consider that what studies may have deemed to be an, an advanced maternal age in 2012 is actually different to what is in 2023 considered an advanced maternal age. Absolutely. I thought I, I, I think it's brilliantly put in, in [00:17:00] terms of those limitations, and I, I personally, I, I think they're there, but I think it doesn't devalue the data anyway.

I think the data is very clear and it's consistent as well. When you look across those studies and you've got really great tables in the paper, which, which report these things and you see these consistent themes coming out. But I think that was a really interesting point. The last one is, you know, you know, we move on very quickly now, don't we?

And like you say, in 2012 to over 10 years ago now, things. Have changed, haven't they? And I think that's really important to take into account. Catrin, if I maybe come back to you briefly, one thing I read thought about when I read through this, this study was, you know, it just kept coming back to me, how do, how do we or our specialty compare to other surgical specialties in terms of, of these findings?

Yeah, so I think our specialty is, is pretty similar. I do think it has some unique occupational hazards that aren't as, aren't necessarily present in other specialties. But in keeping with the findings of the systematic review that we mentioned earlier by Todd et al, looking at all [00:18:00] surgical specialties, our findings were, were actually pretty similar.

Mm-hmm. But interestingly, there was a meta-analysis of 62 studies, which looked at occupational shift work, so not necessarily healthcare, but that demonstrated that pregnant women who work rotating shifts. Fixed night shifts or longer hours have an increased risk of adverse pregnancy outcomes, which included the premature labour, which was in keeping with the findings of our study, and also those of Hamilton et al.

And I think this has also led to the development of guidelines from societies such as the British Orthopaedic Association with guidance on, you know, when they would recommend a pregnant trainee coming off the on-call or shift night shift rota, for example. Absolute. Absolutely. And I think, I think like you say, that, that guidance is very much, was very much needed when it came in.

And I think it's, it's very clear the, the impact that has on, on those shift patterns. And I think having that guidance is so important for our trainees and, and for our, and for our, our consultants alike, you know, who in [00:19:00] that situation. And I think Lily, if I could maybe come back to you though, just you had just mentioned about the occupational, how hazards in our specialty, which you told us about.

How do you interpret these and do you think, you know, does the current guidance or there's any changes to guidance that we need to maybe implement in relation to that, do you think? Sure. So the thing is, we, there's little to no evidence to support increased risk to the pregnant surgeon. However, that's probably because research hasn't been carried out in this area because of the potential or theoretical risk to either the, the pregnant person or to the onboard child.

Not that that. It's not that there is no evidence for it. Yeah. And PMMA we know can be toxic at high levels. However it has been shown that these levels can be reduced if we use pre-packed vacuum mixing systems. And I think many, many hospitals, certainly in the UK do do this. Mm. And you have, there's an increased distance as well, so you stand further away from the vapour source and when you're doing a [00:20:00] arthroplasty. However, data actually sort of demonstrates this lack of consensus amongst female orthopaedic surgeons, whether they should remain in the operating theatre to join the cementing part or not.

And as you said, there's, we, we know there's a high risk of congenital abnormalities compared to the general population, sort of 6% versus up to 3%. And a, a recognized risk factor is exposure to radiation. And the, the unborn child is most vulnerable in the first trimester. And the International Commission on Radiological Protection has set this target or limit of one milligray for the duration of pregnancy.

And it's important for everyone to know that there's no legal obligation for the orthopaedic surgeon to continue to use radiation during pregnancy. And if they choose to do so, their, their hospitals should consider providing them with a dosimeter so that they ensure that that maximum exposure of one milligray is not reached.

Another study by Cho et al shown that there's an increased prevalence of breast cancer and or course cancer in female [00:21:00] orthopaedic surgeons. And we know that lower parity, nul parity, and greater age at first child are all risk factors associated with cancer. And additionally, the, the pregnant or, or even not pregnant female orthopaedic surgeon may be less likely to fit into the standard issue hospital lead gowns, which, you know, we are often that kind of.

Quite large tabard appearance and it's been demonstrated that if we add lead sleeves or an axillary supplement that can, that really improves the protection of the breast and the axillary tail, and reduces the radiation exposure to this sort of very sensitive tissue. And in fact, the British Orthopaedic Association has actually been working with our industry partners right now to produce a design that covers this lateral chest wall axillary tail to be able to protect the upper outer quadrant of the breast to help reduce this risk.

I thought, I thought that was really interesting, actually. And like you said, that's, I think that's ongoing work, isn't it? About the developing this, these, this different type of lead gown. I think [00:22:00] obviously so important and actually, you know, out with what we've been talking about here, which obviously pregnancy and, and, and, and fertility the all course cancer risk itself is, is, is, is, and the increased risk of that is also such an important issue.

So both, maybe just to finish up maybe Catrin and I come to you first, you know, and what, what are your thoughts on this overall in terms of, and, and maybe anecdotally as well about the barriers to pregnancy in our specialty and how these and, and the other issues we've discussed here today could, you know, can be, we can sort of move forward with them and, and make things as, as, as o o optimal as we can.

Yeah, so I think the findings of the systematic review that I don't think they're surprising, but I think the results are very important to discuss and we'll also really be grateful to be given this platform to discuss them. And I think it's really important we're doing so. I feel we should be able to create a culture within our specialty that allows and supports female orthopaedic surgeons to have children when they [00:23:00] want to, and they shouldn't feel they have to delay childbearing due to a career in orthopaedics.

They should be able to coexist. Yeah. And there remains an urgent need for more recognition of issues surrounding pregnancy and child bearing to change this perception and to create a more supportive environment for the female orthopaedic surgeon. I, I totally agree Catrin, I think that's very well put. And, and Lily, sort of to finish off, you know, in terms of.

Maybe you could highlight, you know, the, what some of the current guidance for, from that we there is out there for our trainees and, and, and, and female orthopaedic surgeons alike, you know, that we currently have out there and how they maybe compare internationally maybe. Yeah. So societies in the UK, so the BOA and in North America they have called Ruth Jackson Orthopedic Society.

And they're based really leading the way with publishing guide, lots of guidelines on how to support orthopaedic surgeons through pregnancy. And as with, with breast cancer and the ac the axillary protection we just talked about, and also the [00:24:00] Royal Australasian College of Surgeons is following suit in the up to date 2022 to 26 strategic plan.

And I'd and also for our local listeners the BOA does publish guidelines actually also for educational supervisors and clinical trainers, and it's, it's a really invaluable resource that addresses topics such as we've talked about, occupational hazard, breastfeeding, flexi working and returning to work following pregnancy.

And I think it's worth a listen. Absolutely. Absolutely. Well, well, well, both, I'm afraid that that's all we have time for today, but a really, a sincere congratulations on, on what I think is an outstanding study and I, I, I thank you both so much for not only taking the time to join, join me today, but I think for highlighting such an important area for our specialty and, and really highlighting how we can improve the support and the environment for our colleagues moving forward.

And I think it's been great to have you both with us today. I really appreciate it. And to our listeners, we do hope you've enjoyed joining us and we encourage you to share your thoughts and comments through social media and like feel free to tweet or post [00:25:00] about anything we've just here to discussed here today.

And thanks again for joining us. Take care everyone.