Careers in Reproductive Healthcare

CAREERS IN

REPRODUCTIVE HEALTHCARE

Institute Research Number 304 ISBN 1-58511-304-2

CAREERS IN

REPRODUCTIVE HEALTHCARE MEDICAL DOCTORS, NURSES, TECHNOLOGISTS DEVOTED TO HELPING COUPLES ENJOY THE BLESSING OF CHILDREN MOST PEOPLE BELIEVE THEY WILL

someday have children, and most of the time they do. However, for some people it is extremely difficult to have children. These people turn to reproductive healthcare professionals in order to realize their dream of becoming parents. Infertility has risen in the past 20 years, due to a number of societal changes. With the increase of two income households and each spouse having an equally demanding career, childbearing has often been delayed until couples are in their late 20s or even 30s. It’s a fact that after age 30, fertility is compromised for both sexes, and it only gets worse as the years pass. Add to that the possibility of healthcare issues such as high blood pressure and diabetes, as well as strictly female difficulties like endometriosis, and the trend becomes clear. 2

In many countries around the world, age is not the prevalent cause of infertility but, rather, disease. Women who are unable to have children are ostracized, even abandoned by their spouses and families. The rates of infertility are highest in sub-Saharan Africa, where the high rate of sexually transmitted diseases may account for the high infertility rate. For purposes of definition, infertility applies when a couple fails to conceive after at least one year of actively trying. Fifteen percent of couples experience some degree of infertility. And it is not just a medical condition, but an emotional and social condition, as well. An entire sub-category of therapy has grown up around the problem. Although less stigma is attached to childlessness in this country, being childless is no less devastating. It can be painful to want a child so badly, to be disappointed month after month, and then watch friends and relatives have one or more babies with seemingly no effort. It places a strain on family relationships and, especially, on the marital relationship. Many marriages simply don’t survive infertility. As you probably already know, in order to conceive a child the male sperm must reach and fertilize the waiting female egg. Sounds simple, right? However, many women do not regularly ovulate, making it difficult to choose the right time to conceive. Many men have low sperm counts or sexual performance problems that stand in the way of conception. Suddenly, it’s not so simple anymore. In this country, male factors account for about 35% of overall infertility, and female factors account for another 35%. Some infertility is the result of both male and female factors, and some cannot be explained at all. When couples finally seek help for infertility, they typically go to a doctor who specializes in reproductive healthcare, commonly known as a reproductive endocrinologist. They may be referred by their family physician, or the infertility specialist may also be the woman’s gynecologist. The first appointment includes a meeting with the doctor and can take up to an hour and a half, as the doctor and the couple become better acquainted and a history of attempts to conceive is established. The couple completes a questionnaire and the woman has a complete medical examination. Three to four more visits follow, in order to perform a series of tests. Then the couple returns for a final consultation, to hear specific treatment options. 3

Based on this research, the doctor may encourage the couple to try the natural approach once more, assisting them with the correct timing for conception. Some general guidelines to increase fertility include monitoring ovulation and timing intercourse, quitting smoking, drinking and drugs. Men can wear boxer shorts instead of briefs to improve sperm quality. Other guidelines include nutrition, exercise, perhaps even different positions for intercourse. After a specified period of time, other options will be explored. In vitro fertilization, the most common infertility procedure, is also known as test tube fertilization. It involves a complex process: The woman takes medications to make multiple follicles begin to develop in the ovaries Ultrasound is used to monitor follicle growth, to determine egg growth and uterine lining development At the appropriate moment, a trigger shot of Human Chorionic Gonadotropin is administered Thirty six hours after the shot, the retrieval of the eggs begins using ultrasound guided needle aspiration; a sperm specimen is washed and prepared for insemination; the washed sperm is then placed in a dish with the eggs and they are placed in an incubator for eighteen hours; fertilization is closely observed Embryos are transferred into the uterine cavity via a tube inserted through the cervix. The number of embryos for this procedure depends on the desire of the patient and the patient’s age. If the patient is under 35, up to three embryos; if the patient is 35 or older, up to four embryos. Additional embryos may be frozen for future use. Ovulation Induction is another method. A fertility drug taken by mouth induces ovulation. The dosage usually starts at 50 mg. but can be increased if circumstances dictate. Ovulation Induction can also be accomplished by injecting the patient with hormones which induce ovulation within a 10 day period. Patients are closely monitored with ultrasound during this treatment.

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Intrauterine Insemination, also known as artificial insemination, is another popular procedure. A catheter is placed into the cervix and a sample of washed sperm is injected into the uterus, where it can proceed to the waiting ovum. The procedure may require more than one cycle to be successful; a patient can undergo six cycles before more aggressive treatment is attempted. In some cases, infertility is the result of a tubal ligation, a voluntary surgical procedure where the fallopian tubes are tied to prevent fertilization of the ovum. This procedure can be reversed, and the surgery is done on an outpatient basis. With the surgery, there is no guarantee that a child will be conceived, especially in older females. Once conception takes place, the pregnancy is watched a little more closely then the average, monitored for abnormalities or other problems. When the baby is finally born, the anguish of the past years all fall away as the dream of a new human life is realized.

HOW TO FIND OUT MORE BEFORE YOU PURSUE ANY HEALTHCARE CAREER, YOU MUST BE ABLE TO EXPLAIN

why you wish to do so. Did someone close to you suffer an illness, so you learned more about medical matters than you might have otherwise? Was your family physician especially kind and understanding? Have you always wanted to help others with their problems? You will be asked this question over and over. Starting with your high school guidance counselor, everyone you talk to will want to know your motivation. Your answer to this question will be scrutinized especially closely if and when it comes time to enter medical school. Admissions committees want to be absolutely sure of your commitment before they will admit you. Once you have a fairly good idea of why you want to work in the healthcare field, take some time to plan. In junior and senior high school, study biology, chemistry, mathematics, health and related courses. If you find yourself struggling in any of these areas, get help as soon as possible. Even if your grades appear to be less than acceptable for medical school, there are many other options for a healthcare career.

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In college, plan a strong pre-medical series of courses. This should include all levels of study in physics, biology, math, English and chemistry. Or choose a school that has a nursing degree on which you can set your sights. Most healthcare professionals go into a general medical field, then specialize later. For instance, you might go to medical school, finish your residency and work for a few years in general medicine. Later, you might become interested in a particular specialty like reproductive healthcare, so you will need to continue your education to attain the next level. In some cases, this will be a fellowship in your chosen field. To become a doctor, you need to complete many years of school. After high school and undergraduate college, you will go on to four years of medical school, then three more years of residency before you can become a board-certified physician. For most people, this means you may be close to 30 years old before you become an MD. Then, if you choose to specialize, you will need between two and six years more schooling, depending on the specialty. A gynecologist has two to three more years of schooling than a basic general practitioner, with a reproductive endocrinologist needing two to three years more than that, usually in a fellowship situation. Find out more about what it really means to be a doctor by talking to doctors, starting with your family physician. Let the doctor know you will appreciate completely honest answers, because you are trying to make a career choice. Also talk to your school guidance counselor for advice on what classes to take. If medicine interests you but you don’t have the desire to become a practicing physician, there are many other choices you can make. Many doctors prefer to be researchers or teachers rather than clinical physicians. If you are put off by the time and work commitment it takes to become a doctor, consider registered nursing as an alternative. For a first step, talk to your school nurse about what it means to be a nurse, what experiences the nurse has had within the profession. Take a first aid or CPR course to get an idea of the procedures involved in caring for another person. Volunteer at hospitals to experience the atmosphere of a healthcare facility, and to broaden the base of your relationships within the field.

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The first step to specializing as a nurse in the reproductive health field is to become a registered nurse. You can take a two year associate’s degree program, a two or three year diploma program, or a four year bachelor’s degree program. These programs are offered at colleges and universities. To obtain a license, you must pass a state board examination. From there, it’s a matter of focused continuing education and strategic job selection in order to become a nurse specializing in reproductive health. Working in a maternity ward is an excellent place to begin. If you are more interested in the strictly diagnostic side of medicine, becoming a sonographer, or ultrasound technician, might be right for you. The sonographer in a reproductive clinic takes ultrasounds of a woman’s pelvic region at the time of the first examination, as well as periodically at critical times throughout the assisted fertilization process. To pursue this career path, take the most challenging science, math and English courses available in high school. From there, you will proceed to a community college or hospital, where the program lasts from one to four years, depending on prior work experience. If medicine still interests you but you are not as thrilled about direct patient contact, being a medical technologist might satisfy your desire to help people while remaining somewhat distant from hands-on patient care. The time it takes to become a medical technologist varies according to your personal choice. You can attend a vocational or technical college for 12 to 15 months, obtain a two-year degree at a community college, or go after a four-year Bachelor of Science degree at a college or university. For medical technology, begin your preparation in high school, concentrating on chemistry and biology, with a special emphasis on conducting exacting experiments. See if your family physician knows anyone in the field to whom you might talk to about the career. For a description of the job, the Internet has dozens of good resources, including the association sites.

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HISTORY OF REPRODUCTIVE HEALTHCARE WHILE REPRODUCTIVE ENDOCRINOLOGY IS A RELATIVELY NEW SCIENCE,

expanding as reproductive technology has expanded, the obsession we as human beings have with reproduction goes back many thousands of years. In ancient societies, childlessness was considered unacceptable, and usually the female was blamed. Polygamy may have come about in order to maximize the chances for having large families. A large family, or clan, meant strength and power, the ability to outfight or outlive your enemies. Having children was more than just a means of continuing the human race or establishing a power base. People had children as a means of assuring themselves of care and comfort in their old age. Couples who were childless had to struggle in later life to feed and support themselves, and other members of the society were too busy with their own families to have much compassion. So, a tradition grew up valuing the birth of children in almost every ancient society. Primitive people assumed that childlessness was socially irresponsible or even evil. Being able to continue the family became, for some societies, a rather determined pursuit. In ancient Egypt, the Pharoahs were obsessed with the purity of their own bloodline, believing themselves divine. Therefore, brother often married sister in order to ensure this purity. If they only had female children, the father might marry one of his own daughters for the same reason. The common people, while desiring sons to carry on the work of fathers and provide for them in old age, were more practical, even monogamous, although a man could abandon his wife if she did not bear children. In ancient Greece, and later in Rome, sons were more highly prized than daughters, again with the aim of continuing the family’s blood line. Throughout the ancient world, it was always assumed that the daughter was absorbed into the family into which she married, while the son remained within the father’s family. If no sons were forthcoming, adoption of a younger high-born son was arranged in order to ensure the continuation of the family line.

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In Persia, children were an absolute necessity if a couple was to be respected by the society in which they lived. Sons were more highly valued, because Persia was a military society, and sons would grow up to be soldiers. Here, to ensure the birth of many children, the harem system was established, a form of polygamy for prominent and aristocratic men. For all of the ancient people, fertility was a central concern. Of course, they did not have the techniques of modern science and medicine available, so they resorted to herbs, witchcraft and prayer to conceive. Almost every society in the world worshiped a goddess of fertility. Hopeful women would sacrifice to the goddess with the hope that their sacrifice would be well received, and they would be rewarded with children. The only ancient civilization where fertility was not encouraged was Japan. In very early years, when population was scarce and land plentiful, the number of children born was immaterial. However, as the population grew and the land could not be increased on the island, new restrictions were introduced. Finally, it became nothing less than the height of social responsibility for Samurai to wait until 30 to marry and then to have no more than two children. With the rise of the upper class in Europe, kings became eager to establish dynasties in order to ward off their powerful noble families, so it was absolutely essential that they marry and have sons. Until Britain’s Queen Mary took the throne in 1549, Europe had never seen a female head of state. In fact, so anxious were kings to have a male heir that divorce of a sonless wife was allowed by the Catholic Church in order for kings to remarry, although it was formally known as an annulment. It was Henry VIII, Mary’s father, who first pushed for a formal divorce due to the lack of a son to carry on the Tudor name. When the pope would not grant his divorce from his first wife, Catherine of Aragon, he made himself head of the English church, gave himself a divorce, and married Anne Boleyn. When she too failed to produce a son, he simply beheaded her to make way for his next wife. Just as in ancient times, anxious women turned to herbal remedies, prayers and witchcraft. Witchcraft was especially dangerous, because witches were thought to serve the devil. If a woman was caught performing a spell, she could be executed. Yet these methods seemed to work often enough to gain some credibility. 9

Marie Antoinette, wife of King Louis XVI of France, suffered the gibes of the French people when she had trouble conceiving. Until very recently, it was assumed the woman was always to blame for infertility, even though in this case the fault was that of King Louis. They were eventually able to have children, but not before Marie Antoinette was openly derided and despised by her adopted country. During Victorian times, when faced with a case of childlessness, doctors would carefully advise the childless woman to take medicinal waters. In other words, the doctor would have suggested taking a trip to relax. During this most conservative of eras, that was the best that could be done or even talked about. Both the American Society for Reproductive Medicine and the American Society for Medical Technology were established in the 1930s. But it wasn’t until the late 1970s that the first successful in vitro procedure was accomplished. Since then, this procedure has been responsible for about 300,000 live births around the world. Although the Roman Catholic church has condemned the process, childless couples continue to explore this and other fertility options in their endless quest to become parents.

Now, with drugs and laboratory procedures,

infertility as a problem is out in the open and being addressed all over the world. Not only are childless couples experiencing the joy of having one or more children, but even high risk children stand a better chance of survival than every before. Babies born as early as 25 weeks and weighing only a pound have been known to survive today.

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WHERE THE JOBS ARE PHYSICIANS, NURSES, MEDICAL TECHNICIANS AND SONOGRAPHERS WORK IN LARGE

and small hospitals, private offices, clinics, research facilities, laboratories, government agencies, public health or home healthcare agencies, colleges and universities. They are located everywhere in the United States, in cities, in the country, in rural areas and in the Peace Corps overseas.

General medical personnel are always in demand, especially if you are willing to relocate to where the work is. When you specialize in reproductive health, or any other specialty for that matter, your choices will become more narrow. Most endocrinology clinics or hospital units are located in larger metropolitan areas. In rural areas, clinics that specialize in reproductive health are almost always oriented primarily toward gynecology and obstetrics, with reproductive endocrinology as an additional service. As a reproductive healthcare professional, you may work right in the hospital with patients, or in the lab. You might also work in a private clinic with its own building, or a clinic located in a series of offices, often in the same general medical field. For instance, your reproductive health clinic might be located where there are one or more gynecological offices. Reproductive healthcare services can also be found in the auxiliary buildings of hospitals, often known as doctors’ office buildings. The typical private infertility clinic consists of one or more doctors, one or more nurses, a medical technician/embryologist, an office manager and support staff, including front desk receptionist and secretaries. Most also include a sonographer to administer the necessary ultrasounds. The office will probably contain a private office for each doctor, two or more examination rooms, a waiting room with adjacent records and secretarial office area, a restroom for patient use and an ultrasound room. It may also contain a conference room and break room for the staff. The doctors and nurses typically work in the examination rooms for most of the time. The doctor updates patient records and confers with patients face to face in the office. Medical technologists are usually found in the laboratory, and sonographers perform their tasks in the room where the equipment is located. 11

Doctors and nurses also work in hospitals, if they participate in the delivery of the babies which they have helped to conceive. Doctors can also work at colleges, universities and medical schools as part-time instructors in their field of expertise. They also attend conferences and association meetings in order to network with other professionals in an effort to keep a steady flow of patients coming to the practice.

THE WORK DUTIES PHYSICIANS OFTEN WORK 60 HOURS A WEEK OR MORE. NURSES, SUPPORT STAFF

and technicians typically have more predictable hours, 40 or less a week. Physicians have unpredictable hours, often on evenings or weekends. They are often on call in case of emergency.

Doctors Doctors work primarily in their own offices, performing examinations of patients, consulting with the patient to offer treatment options and test results, consulting with other physicians when in doubt about diagnoses, and performing surgery. When patients are in the hospital, it is customary for the doctor to visit them once a day; this practice is called rounds. After seeing each patient, the doctor must either write the account of the examination on the patient’s chart or dictate the details into a cassette recorder. With computers so sophisticated now, many doctors are keeping patient charts in the database and entering the notes directly into the patient file. The doctor must also keep abreast of insurance plans and changes, as well as oversee the general operation of the clinic, including billing and payroll. In very large clinics with more than one doctor, there will usually be a business manager to take much of this clerical burden off the doctors’ shoulders. One of the burdens that only the doctor can bear is that of the practice’s success. It is extremely important for the doctor and the whole staff to promote the practice, wherever they might be. The infertility field is a huge business, with potential huge annual profits. But it is the practice that pushes itself forward, into the public eye, that gets the most business.

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Therefore, the doctor should ask for referrals whenever possible, in the most tasteful way, of course. The doctor might also consider advertising on radio, television or in local publications; even radio or television appearances are possible and would probably be a good investment. Many doctors dislike this aspect of their business but, if it is neglected, one day you may come to work and there will be no patients in the waiting room.

Nurse The nurse greets and prepares patients for their examination

by the doctor. This might include listening to the patient’s heart, taking blood pressure, finding out what medication the patient is currently taking and adding all this information to the patient’s chart. One of your biggest duties at this time is to listen to what the patient is saying, and watch the patient’s body language for any additional clues as to the patient’s emotional state. In addition to listening, it is often the nurse’s job to talk to the patient, to answer questions, and to calm the patient with soothing words. Many people are afraid to go to a doctor for a regular checkup. Just think how it feels to be seeing a doctor who may be able to help you grant a lifelong wish – having a baby. There will definitely be feelings of stress and anxiety. Nurses, especially in the reproductive health field, assist at surgical procedures, such as the harvesting of eggs for in vitro fertilization, or the intrauterine insemination. At the doctor’s direction, they may administer the medication for ovulation induction or the injection for ovulation induction. Besides the fertilization procedures, the nurse may also be required to assist at the birth of the child, if the doctor is also a gynecologist. This means following the doctor’s instructions during the labor, being present and ready to assist no matter what happens. The receptionist will often bring patient questions or concerns to the nurse first, who will consult with the doctor and may call the patient back with answers. Therefore, you must know the answers to a variety of questions, including but not limited to medical matters, insurance plans and what each procedure involves. The nurse can operate independently of the doctor in many instances, but theoretically is always under the doctor’s supervision.

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Sonographer – Ultrasound Technician

The sonographer, or ultrasound technician, administers ultrasound so a physician can view the internal organs, like an x-ray only without the damaging radiation. To have an ultrasound you do not need to wear a lead apron. The sonographer keeps a schedule of appointments and must be on time in order not to keep the next patient waiting. In a reproductive clinic, the sonographer does the ultrasound at specially determined stages of the infertility treatment. Therefore, the sonographer must keep in close touch with the nurse and doctor and adjust the ultrasound schedule according to patient requirements. If the clinic is also a gynecological one, the sonographer will also schedule and perform ultrasounds at various benchmark times during the course of the pregnancy. As a result of the ultrasound, there will be films produced of the patient’s internal organs. These films must be processed and stored correctly, another aspect of the sonographer’s job. Because the sonographer deals directly with patients, an important component of the work duties is to interact with patients. Some patients will be nervous about the procedure. They will want to know everything that’s going on, to be able to see what the sonographer sees on the screen. Therefore, it is essential that you are comfortable teaching patients about the procedure, what the purpose of the ultrasound is, and to calm the patient if possible. If the ultrasound is being conducted during pregnancy, the patient will want copies of the films, as well, in order to show the baby to relatives and friends before it is born. After the ultrasound, you will be responsible for updating the patient’s chart with information about the test, and even information about the patient’s demeanor. The films must be placed in the file for the doctor to consult, and you may confer with the doctor about the results of the ultrasound; the doctor may solicit your opinion about the films.

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Medical Technologist

The medical technologist who specializes in reproductive health will assist in bringing the ovum and egg together to produce an embryo, then a fetus and, ultimately, a newborn baby. This can all be done without the technologist meeting the parents and indeed, in the case of a remote laboratory, that is exactly how it is done. The technologist performs the in vitro procedure, fertilizing the egg with the washed sperm in a sterile environment. After the eggs are first received, the tech will store them appropriately until they are ready to be fertilized. The sperm sample is washed in preparation for use in fertilization. The protection of all samples is a critical function. Great care is taken to ensure that sperm samples and embryos remain viable for as long as possible. Besides handling the samples, the technologist must create and maintain computer records. You will have to be able to account for the samples and embryos when the doctor or other official inquires about them. You will work closely with the doctor to schedule the procedures for fertilization, often working under the pressure of tight deadlines. As a technologist, you will have little contact with the patients, except perhaps to be introduced as part of the fertility team. The majority of your work will be done behind the closed doors of the lab.

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REPRODUCTIVE HEALTHCARE SPECIALISTS TELL YOU ABOUT THEIR CAREERS

I Am an IVF Nurse “Getting into reproductive medicine wasn’t really a career goal for me; it actually happened quite by accident. I had worked in a teaching hospital in labor and delivery. During that time, I worked with many residents, including my current employer, who was at that time finishing his OB/GYN residency. He went on to do a fellowship in reproductive endocrinology. When he got ready to open his practice, he called to see if I would be interested in working for him doing infertility. I hesitated since I knew nothing about infertility. But his persistence and my curiosity got the better of me, and I decided to give it a try. Both physicians in the practice were very patient with me and answered all my questions. I felt like I was back in school but at the same time it was exciting to be learning something new. I had no idea how widespread infertility is, or the number of procedures we now have to treat it.

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The appeal of this job was enhanced by the hours, mostly daytime, Monday through Friday, with only an occasional weekend. Because I have a large and demanding family, this really fit much better than the 12-hour shifts I had been doing at the hospital. The practice has really grown since I joined it in 1997. My title is the IVF Coordinator. I am responsible for the preparation and education of the couples who are our patients, preparing them to undergo an in vitro cycle. I also assist with the surgical egg retrievals and embryo transfers. My day usually begins about 6 a.m. at the hospital where we are currently doing our egg retrievals and embryo transfers, since that is where the IVF lab is located. We are in the planning stages of building our own free-standing facility that will include our office and the IVF lab as one unit. After meeting with the couple, giving them their discharge instructions, I assist in the operating room in aspirating the eggs. Then I go to the office where I return phone calls and e-mails about IVF, consult with patients preparing for IVF, do injection teaching for patients, interview potential egg donors, and occasionally help the lab with their blood draws. Coordinating everyone’s cycles and making sure they understand the process is probably my biggest job. I also spend a lot of time just listening to frustrated patients talk about their infertility. We do have a counselor that we refer all of our IVF patients to, but most patients become very connected with me because of the sensitive nature of their problems. I do enjoy the closeness that I am able to develop with my patients. I am able to get excited with them when they get pregnant and cry with them when they don’t. This is probably the best and worst part of my job. The emotional roller coaster is incredible and it can be exhausting. These couples are what I call “high need patients.” They can become very demanding and self-centered. I believe this is because of the history of their disappointments.

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I have an Associate of Science in Nursing Degree and have taken some additional coursework through the years, here and there. It is no secret that monetary compensation is tied to your educational level. I am a member of the American Society for Reproductive Medicine. They provide some interesting conferences once a year and produce a monthly magazine called Fertility & Sterility. To prepare to be a nurse in reproductive medicine you need a combination of a lot of different areas: basic nursing skills, psychology, biology, zoology, science and medicine. It requires good organizational skills, and the ability to work with all kinds of people. It is rarely boring, and is such a cutting edge field of medicine that things are constantly changing and challenging you to learn something new.”

I Am a Reproductive Partner Physician “I decided to pursue this career

because it’s the most interesting aspect of Obstetrics/Gynecology and is also the shortest path within the OB/GYN from research to clinical application. My specialty is Reproductive Endocrinology and Infertility, a sub-specialty of Obstetrics and Gynecology. My educational background is extensive, like any doctor who has specialized. I went to high school in Pennsylvania and received my bachelor’s degree in zoology from Penn State. I also received a PhD in Immunology. I did postdoctoral research at the Albert Einstein College of Medicine in New York City and received my MD from the State University of New York. My residency was in Obstetrics and Gynecology at Duke University Medical Center in North Carolina, and finally, I completed a fellowship in Reproductive Endocrinology and Infertility at the University of North Carolina, Chapel Hill. My daily responsibilities include patient care during appointments, preparing procedures and surgeries, and teaching residents. Helping couples conceive is very rewarding and it’s the best part of the job. The worst part of the job is dealing with insurance companies and the paperwork that is required.” 18

I Am a Reproductive Endocrinologist “I chose this profession because it seemed very interesting. I did a rotation in medical school in an infertility division in New York City and loved it. My education consisted of fours year of medical school, four years of an OB/GYN residency, then three years in a reproductive endocrinology fellowship. I was on staff teaching in a medical school for three years. Then I went into private practice. My job involves seeing women and couples with reproductive, hormonal and infertility problems. It can involve surgery, medical treatments and in vitro fertilization. Additionally, I am a member of the American College of OB/GYN and the American Society for Reproductive Medicine. This specialty is among the most rewarding in all of medicine. We help couples who may have been trying for years to have children and have a family. There is no better gift you can give to anyone. It is also among the highest paid fields in all of medicine. The part I like least is that it is a very competitive field of medicine with a lot of advertising and marketing necessary to promote a practice. This is a great field of medicine, but you need to be extremely dedicated because it is a long, competitive road.”

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PERSONAL QUALIFICATIONS IF YOU WISH TO BECOME A DOCTOR IN THE FIELD OF REPRODUCTIVE MEDICINE, IT

is a good idea to cultivate patience. You have years of schooling and advanced training ahead of you. You must become and remain goal-oriented, always keeping your eye on the end result even while applying fully yourself to the task at hand.

It is important for you to be able to relate to people, to identify with their pain, to feel compassion for their difficulties. You must want to help people, because that’s what reproductive healthcare is all about, helping people realize their dream of becoming parents. At the same time, for your own mental health, you must have the ability to understand that you cannot help everyone who comes to you. Even with the latest scientific advances, infertility remains something of a mystery; the cause cannot always be determined. Therefore, you will not experience 100% success and you must not internalize that fact. If you blame yourself every time a couple does not conceive, it could hamper your efforts on behalf of those who can. From a strictly academic standpoint, you must have strong science and math skills. If you cannot succeed in these areas, you would probably be better off in another field. Becoming a nurse in the reproductive health field requires many of the same personal qualifications as becoming a doctor. However, the length of time spent in school and training is much less; the path to reach your goal is not nearly so many years away. The most important qualification a nurse can have is a calm and controlled, yet warm and compassionate attitude toward your patients. Many of them have endured years of disappointment as their hopes of having a child are dashed again and again. They may become overly emotional, cry, even sob hysterically, or exhibit other strong emotions. It is up to you to soothe the patients, comfort and reassure them. Another important qualification is the ability to stay organized and on schedule. Your days will be busy, meeting with patients, assisting with surgery, dealing with insurance matters. Such a schedule can easily overwhelm, and then slip totally out of control. If this happens, you not only short-change your patients and the physicians with whom you work, but you harm yourself and compromise your professional standing. 20

A nurse must be willing and able to take orders from physicians and carry them out. Even if you disagree with the doctor, you should not challenge the physician, especially in the presence of a patient. The patient is relying on you and the doctor and other staff members to be strong and consistent in treatment, and you should not let them down. Before you can become a sonographer handling the ultrasound examinations, you should be comfortable around all kinds of equipment, especially imaging and computer equipment. If you do not understand everything about how the machine works, it will be hard for you to explain to patients what it does. As a sonographer, you will be expected to be proficient with all equipment that involves your responsibilities. This may include maintaining the equipment so it stays in good working order. At the very least, you will need to know and utilize the most current standards of sanitation. These may involve cleaning the machine between uses, wearing plastic gloves and mask during procedures, and protocols. Besides working with equipment, you will also be working with people. That means you need to cultivate compassion and patience, trying to put yourself in their place, to understand their needs. A medical technologist needs excellent hand and eye coordination, as well as a steady hand. You will be working with material that can be seen only with a microscope, and carelessness can easily compromise a procedure. Attention to detail in this work is also essential. As much as possible, you must maintain 100% accuracy in order to ensure the success of the procedures. These lab specialists must also have the ability to work under pressure. Fertility procedures are frequently time-sensitive – for instance, the eggs are harvested exactly 36 hours after the hormone shot, then placed in a dish with the washed sperm for exactly 18 hours. If the eggs are not processed in a timely manner, or the sperm is washed too soon before joining the eggs, fertilization may not occur. For all of these jobs, you need the ability to work with others in a team setting. It is important to realize that no single person is wholly responsible for either the success or failure of the infertility treatment. You each have a part to play, a job to do, and, if you do your job, you will succeed as a team. 21

ATTRACTIVE FEATURES ALMOST EVERYONE WHO WORKS IN THE REPRODUCTIVE HEALTHCARE FIELD SAYS

that the most rewarding thing about it is seeing how happy the patients are when the wife finally becomes pregnant. After years of disappointment, they are going to realize their dream of becoming parents at last.

No two days are ever alike for any of the jobs connected with the field, so the likelihood of becoming bored is very slight. While the days may be hectic and it is extremely important to stick to the schedule, it can be exciting to be busy all the time. Many people who choose emergency medicine thrive on the pace and, although not quite as demanding, the sense of urgency in a reproductive health clinic might be just as stimulating for you.

As a doctor, you will have the opportunity to improve

on nature and give people the chance to be parents who seemingly were not destined to be. It is challenging but rewarding to determine the causes of infertility and to be able to rectify them. It can be a powerful feeling to know you have the technology to help people overcome physical disability. As a nurse, you can expect to enjoy more regular working hours than if you worked shifts in a hospital. Most of the time, you can count on being home with your family nights and weekends. But even better is when you see the babies which are born as a result of your work. You might even encourage the doctor to keep a photo album of the babies that resulted from your work, for prospective parents to look at as they wait for their own miracles. As a sonographer, you will enjoy a stable schedule with set appointments every day. In a hospital setting, you would have to work nights and weekends to be on call for emergencies. That will not happen often when you work for a reproductive clinic. Just as with the doctor or nurse, you are certain to feel a surge of pride when you perform the ultrasound, and the parents are able to see on the screen a viable fetus which resulted from the clinic’s work. After all, you had something to do with that! 22

As a medical technologist in a reproductive clinic, you will be performing very specific procedures, giving you the chance to improve these procedures to peak efficiency. No more tests that span the spectrum of possibility, as in a general laboratory. No more “I need it yesterday” demands from harried physicians. Your primary goal is to preserve viable specimens and use them to produce viable embryos. Of course, scheduling can be tight, but it’s much more manageable than in hospital lab work. You know ahead of time what test will be required and when. And you get to work on the cutting edge of technology. Reproductive health is one of the hottest careers for someone interested in the concepts on human genetics. Finally, the earnings for reproductive health professionals are usually higher than that of other medical fields, especially those of doctors.

UNATTRACTIVE FEATURES PROBABLY THE MOST UNATTRACTIVE ASPECT OF A CAREER IN THE REPRODUCTIVE

health field is the anguish of failure. Like it or not, you will not be able to help every person who comes in your door. Seeing their crushing disappointment after having suffered so many already can be mentally and emotionally debilitating for everyone who has invested time and compassion in the case. Even just delivering the sad news takes time and practice, and some doctors never get used to it. How do you tell people kindly that, after everything they’ve gone through, there is nothing more to be done, they will never have a baby? What will you do if they burst into tears or, worse, if they become angry, even violent? There are many strong emotions surrounding the infertility issue, and when people have endured years of stress related to it, they may not be in the best shape to control themselves when confronted with the unpleasant reality. For doctors, the two most unattractive aspects of reproductive health are the amount of paperwork to be completed and the fact that the field is so competitive. Paperwork in the medical profession is a fact of life, and there are few doctors who wouldn’t complain about it, and the reproductive health field is no different. 23

The reproductive health business is also extraordinarily competitive. A clinic has to invest time and money in advertising, networking and other marketing efforts to ensure a steady stream of patients. Suddenly, having a general practice with a reliable patient base can look very attractive. Being a nurse, specializing in reproductive health, could affect your future in one of two ways: it could make you highly desirable at other clinics or it could make it extremely difficult for you to return to general nursing at some point in the future. Rather than seeing a variety of patients with a wide range of complaints, the emphasis is on a smaller base of needier patients with narrowly defined problems. You might find this boring or stressful after a while. One nurse has characterized infertility patients as “high need patients.” Some nurses might be put off by just how needy these patients can be, self-centered, demanding, working on the assumption that no other patient is as important. It might grind down a nurse’s patience. For a sonographer, it can be a socially narrowing experience to work only in a reproductive clinic. Instead of a hospital full of friends and acquaintances, you are in constant contact with only a few other healthcare professionals. You are the only one in the clinic who is doing what you do, so there’s no one else with whom to share the good and bad stories. For a medical technologist, it is also a narrowing experience. You will be dealing with only one aspect of the field for which you were trained. Perhaps you would prefer to be performing a wider variety of laboratory procedures. For all the staff involved in reproductive health, there is the issue of the public perception of the entire field. In recent years, cloning and the use of embryos for experimentation have come under serious criticism. Many average Americans believe it is wrong to manipulate nature in this way, and some of them may express their outrage in a violent manner. Members of some religious groups, including Roman Catholics, strongly disapprove of some procedures you will be doing on a daily basis. You should certainly consider your personal feelings about these issues.

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EDUCATION MOST INFERTILITY DOCTORS ARE CALLED REPRODUCTIVE ENDOCRINOLOGISTS.

They have two to three years additional training beyond that of an Obstetrician/Gynecologist. However, they must first become a medical doctor (MD) before they can proceed to any specialty. You will, of course, need a high school diploma, with strong GPA and excellent grades in science, biology and mathematics. You should try to get into an undergraduate pre-medical program in the best possible college, although most schools can provide what you need if you are strongly motivated toward your goal. In order to get into medical school, you must maintain an undergraduate GPA of 2.5 or above, although higher is definitely better. The medical school admission process is very competitive. There are 125 medical schools in the United States, but your admission is by no means a sure thing. In one recent year, over 40,000 students applied for the 16,000 openings in medical school; that means less than 40 percent of the applicants were accepted by any school. When choosing which school to apply to, you must try to be realistic. If your grades and admissions test scores are average, you will probably not be able to get into the highest ranking medical school. But that doesn’t mean you can’t get into any medical school. Likewise, if you are passionately interested in one specialty of medicine and the best school for that seems out of reach, try not to sell yourself short; apply, by all means. Be sure to check out the hospital facilities that are associated with any medical school you are considering. You will probably do much of your hospital training at this facility, and if it does not offer a strong program in your area of interest, the school will not be a good choice. After medical school you will do a residency. If you are not sure what field of medicine is most to your liking, you can do a general residency. However, if you know that reproductive health is the area where you most desire to work, try to get an OB/GYN residency. This will enable you to try later for a Reproductive Endocrinology fellowship to accelerate your progress to your ultimate goal. If nursing is your goal, you will still need to do well in high school in science, biology and mathematics, although electives will also become a factor when you enter college. To become a nurse, you can obtain a two-year associate degree or a four-year bachelor’s degree. 25

The associate degree takes less time and costs less, so some nurses get this degree first and get a job in order to save to go back to school for the more advanced degree. Once you have a nursing degree and are looking for a job, you can begin your reproductive healthcare career by trying for a spot in the maternity ward, or even in the reproductive health clinic at the hospital. Once you have spent some time doing this work, you can move on to a private clinic, meanwhile pursuing continuing education in order to enhance your abilities. If ultrasound procedures, being a sonographer, interests you, you should take the most challenging science, math and English courses available in high school. Then you should look into the sonography programs offered at community colleges and hospitals. You will be able to complete them in two to four years, depending on your prior experience. After you complete training, you must pass a certification test; in fact, you must complete this test every year, even after you get a job. In order to become a medical technologist as quickly as possible, you can proceed in one of two ways. You can spend 12 to 15 months at a vocational or technical institute or college, where you will study areas of medical ethics and conduct, medical terminology, basic laboratory solutions and media, basic elements of quality control, blood collecting techniques, basic microbiology, hematology, serology and immunohematology. After your course study, you will perform a clinical practicum (like a supervised internship) in a hospital or clinic laboratory. Finally, you will receive your MLT certification. The other short way to become a medical technologist is to obtain a two-year associate’s degree at a junior or community college, where you will study most of the same subjects. You may instead decide to obtain a Bachelor of Science degree in medical technology at a university or college. This undergraduate degree is highly recommended by employers. In order to be admitted, you must have a minimum GPA of 2.5 overall in high school and a C or better in algebra, calculus and chemistry. You can go further and study for a master’s degree in medical technology. You first need a certification from a recognized national certifying agency to enter the program. Most schools have interim programs that allow you to prepare for certification, if necessary. You will need a minimum number of hours in specialized course work in microbiology, chemistry, hematology, immunology, management or education. Finally, you will need to pass oral and written exams at the end of your course work. 26

EARNINGS REPRODUCTIVE ENDOCRINOLOGISTS, CONSIDERED MEDICAL SPECIALISTS, AVERAGE

$200,000 or more annually. They are among the highest paid of all doctors. There is also a tremendous demand for female doctors who specialize in women’s health, especially gynecology and infertility specialties. It is not unknown for them to earn up to $300,000 annually early in their careers.

To maintain your earnings level, you need to give the best service you possibly can and then solicit referrals from your satisfied customers. For instance, once you are successful in assisting a patient to become pregnant, you might say something like, “I’m so glad we were able to help you. Please tell your friends about the important work we do here.” It is also useful to participate in medical organizations local to your practice. At meetings, you will encounter other doctors who may have patients that need your services. If you favorably impress these doctors, your name will come to mind when their patients bring up reproductive health concerns. This is a positive form of networking. To increase your earnings level, you need to offer services that are better than other clinics, and you need to let potential patients know about it. Maybe you have a 90% success ratio with your patients, or your staff has a combined 75 years of experience in reproductive health. These are points that will attract new patients. Combine them with other important facts about your practice, incorporate them into a brochure, and ask if you can place the brochures in the offices of gynecologists and general practice physicians you know. This is just one aspect of what could be a winning marketing plan for your clinic. As a nurse, your earnings will be dependent on what the clinic or hospital budgets for your services as well as others. The job of Registered Nurse is among the highest in demand of all occupational groups. It will have fast growth, high salaries (over $30,000 to start), and low unemployment. The median income right now is between $35,000 and $45,000, with a Bachelor of Science degree. By branching out from the basic discipline to reproductive health and picking up a master’s degree, you might increase your earnings to as much as $75,000 and beyond, very quickly.

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Your years of experience also count for a great deal in this field. If you spent five years in the gynecology department at a hospital, then five more years at the reproductive endocrinology department, you are worth far more than if you spent the last 10 years in general nursing. You should receive annual cost of living increases as a matter of course, increasing your earnings modestly, but not all clinics do this so it is best to ask up front. Some clinics offer bonuses based on the success and overall revenue of the clinic. It is a fact that the more education you acquire, the more earnings you can command. As a sonographer with the appropriate training and certification, your average salary will be between $30,000 and $40,000. There is a shortage of skilled sonographers, so you might be able to receive a higher salary base simply because you are in demand. This depends on what part of the country you live in, whether you are in a rural or urban area, and how many years you have been certified. You should receive annual cost of living increases, subject to clinic policy. As a medical technologist, you will start at an average salary of $25,000 to $30,000, depending on your geographical area, the size of the community where you live, and availability of registered medical technologists. However, if you specialize in reproductive health, you will earn significantly more money, as you will if you pursue advanced degrees and continuing education.

OPPORTUNITIES THE FIELD OF REPRODUCTIVE HEALTH HAS GROWN TREMENDOUSLY OVER THE PAST

20 years, with new procedures and research opening possibilities only dreamed about. With more couples putting off being parents for longer periods of time, choosing to start a family later in life than at any other time in our history, the need for reproductive health services should grow dramatically. In addition, there is a new development in reproductive technology that may someday revolutionize the way women have children: the artificial womb. If it becomes possible for women to have a baby of their own without carrying the fetus within their own bodies, the field of reproductive health will grow even more.

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No matter what new developments and technologies are in the future, today’s opportunities in reproductive healthcare careers are widespread and varied. If you live in a densely populated urban area, you will find jobs at hospitals and private clinics. Doctors can open their own practices or become junior partners in practices they will eventually own. Nurses will have their choice of jobs, either in private clinics or in hospitals, especially if they have experience. Sonographers and medical technologists with education and experience will also have good opportunities for well paying jobs. If you are willing to relocate to a more rural area and there are no reproductive health services in that area, you will probably enjoy great success as the only resource within miles. For doctors who wish to work in more rural areas, it would probably be best to combine an OB/GYN practice with the reproductive health aspect in order to obtain the widest possible base of patients. Nurses with gynecological/obstetric experience are a natural fit for a clinic that wants to add reproductive health services to its practice. A dedicated sonographer and medical technologist will also complement such a practice, being able to perform their procedures for couples who become pregnant naturally as well as those who need assistance. While insurance coverage is inconsistent today where reproductive health is concerned, that should change in the future. Just as chiropractic and other alternative healthcare have recently come under the insurance coverage umbrella, so should all aspects of assisted reproduction. After, or even during, a reproductive healthcare career, a doctor or nurse can teach courses at local schools or hospitals. This is one other way of attracting potential clients to the practice and increasing business which will, in turn, increase revenue. It may also lay the groundwork for a second career as a teacher, even after the nurse or doctor is no longer actively involved in a reproductive health practice.

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GETTING STARTED IF YOU ARE APPROACHING THE END OF MEDICAL SCHOOL AND YOU ALREADY

know you are interested in working in the reproductive health field, you should try to obtain a residency in gynecology/obstetrics or, if it is available, reproductive endocrinology. Talk with your school’s placement office about the openings that might be available. If there are no residencies in these specialties, general medicine can be a starting point. Then, if a residency or fellowship opens up in either gynecology/obstetrics or endocrinology, you can apply at that time. Before you graduate with your nursing degree, seek out your placement office to see what jobs are available. If you are going to school in an urban area, the chances are quite good that you will find an opening in that city. However, if you wish to work closer to your home town, broaden your search to include that area of the country. Sonographers and medical technologists usually go to school in urban areas, so there is a possibility of finding a job in the same location as the school. However, it may be more rewarding to seek out a job in an area where there is less competition for the jobs. Consult your placement office for your options. Another option is to look at the classifieds of medical publications or, for nurses, even the classifieds of the daily newspaper. One of the best options for finding medical jobs around the country is the Internet. Sites like www.medhunters.com specialize in listing all types of medical jobs from all over the country. While you may be fortunate enough to find employment in the location of your choice, you should also be open to the possibility that you may have to relocate. Some areas of the country have tighter job markets than others, and you would be wise to go where the jobs are. This means you may leave the city where you went to school, which may also be your hometown. We are an increasingly mobile society as people pull up roots and relocate for the sake of employment. Some medical facilities may even offer financial assistance with your move as part of your contract. It pays to ask up front if this is the case.

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ASSOCIATIONS DOCTORS American Medical Association www.americanmedicalassociation.org Association of American Medical Colleges (Section for Student Services) www.aamc.org American Society for Reproductive Medicine www.asrm.org NURSES American Nurses’ Association www.nursingworld.org SONOGRAPHERS Society for Diagnostic Medical Sonographers American Registry of Diagnostic Medical Sonographers MEDICAL TECHNOLOGISTS American Medical Technologists www.amtl.com

INTERNET RESOURCES American Association of Clinical Endocrinologists www.aace.com American Association of Tissue Banks www.aatb.org

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American Board of Obstetrics and Gynecology www.abog.org American College of Obstetrics and Gynecologists www.acog.com American Infertility Association www.americaninfertility.org American Social Health Association www.ashastd.org American Society of Andrology www.andrologysociety.com American Society of Human Genetics www.faseb.org/genetics/ashg/ashgmenu.htm American Urological Association www.auanet.org/index_hi.cfm Androgen Insensitivity Syndrome Support Group www.medhelp.org/www/ais Association of Professors of Gynecology and Obstetrics www.apgo.org/home/ Association of Reproductive Health Professionals www.arhp.org The Endocrine Society www.endo-society.org/ Engender Health www.engenderhealth.org European Society for Human Reproduction and Embryology www.eshre.com Fellowship in Family Planning www.familyplanningfellowship.org 32

International Federation of Fertility Societies www.mnet.fr/iffs/ National Certification Corporation for the Obstetric, Gynecologic and Neonatal Nursing Specialties www.nccnet.org ObGynLinx www.obgynlinx.com/ Pacific Coast Reproductive Society www.pcrsonline.org Polycystic Ovarian Syndrome Association www.pcosupport.org RESOLVE www.resolve.org Society for Endocrinology www.endocrinology.org Society for Gynecologic Investigation www.sgionline.org Society for Male Reproduction and Urology www.smru.org Society for Reproductive Endocrinology and Infertility www.socrei.org/ Society for the Study of Reproduction www.ssr.org/ Society of Reproductive Surgeons www.reprodsurgery.org COPYRIGHT 2006 Institute For Career Research CHICAGO CAREERS INTERNET DATABASE www.careers-internet.org

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