A Fertile Mind
Infertility specialist shares her thoughts on the baby bust, the importance of a positive patient rapport, and women in the workforce.
Family is one of the most important things for us all. – Dr. Sartor
According to The Brookings Institution, a public policy organization based in Washington, D.C., a baby bust is on the way.
A group of researchers associated with the nonprofit predicted that the public health crisis – COVID-19 – and the subsequent recession “would result in 300,000 to 500,000 fewer births in 2021.” A related survey revealed that 34-percent of American women have either delayed their plans to have a baby, or reduced the number of children they’d like to have, because of the pandemic.
“I think that couples who are either young, or already had a child in the nest, COVID knocked down their desire to make a new baby,” said Dr. Belinda “Sissy” M. Sartor, a local reproductive endocrinologist and infertility specialist. “And why? I would say the anxiety related to, ‘Are we going to have a job? What does COVID do to women who are pregnant and to the fetus?’ I think there was just so much uncertainty surrounding it.”
Sartor, however, did not slow down.
She works for The Fertility Institute of New Orleans. Through a well-balanced mix of experience, science, technology, and compassion, she helps individuals of all backgrounds who are struggling to conceive, become parents-to-be.
The fertility clinic temporarily closed during the early days of the coronavirus pandemic, but when they reopened their doors in late May, physicians welcomed a slew of patients eager to receive a consultation and treatment. Although some of those individuals had planned their appointments well in advance, several others did so while in quarantine, contemplating the idea of bringing a bundle of joy into world.
“Times like that, when you’re home and you’re not working full time, you have time to reflect,” Sartor said. “When they are in a reflective, maybe anxious state about the future, they are more likely to be honest: ‘Hey, maybe we should have been pregnant. Maybe we need to push ahead, see what’s going on and get treatment.’ And they also realized that family is one of the most important things for us all.”
Sartor called this “The Katrina Effect,” since a similar trend occurred during the aftermath of Hurricane Katrina in 2005.
“Even when the city was on its knees, once we were able to get an office and open back up, (the office) was really was humming,” she recalled. “The general population was less likely to make a baby. But the infertile population … I think it helped them see that it is time to go get it.”
Moving with the momentum
Sartor boasts more than 30 years of working experience in the medical field.
After graduating from Tulane University’s School of Medicine, she fulfilled a four year residency, training with doctors, in Tulane’s department of obstetrics and gynecology. She then spent three years of a subspecialty fellowship, learning reproductive endocrinology and infertility, in Georgetown University School of Medicine’s department of obstetrics and gynecology.
When Sartor emerged from her fellowship, she and the physicians in her field were expected to become “experts in menopausal medicine, and help patients along with their transition puberty issues,” she said.
“I think the majority of non-academic reproductive endocrinologists pretty much take care of infertility,” Sartor said, foreshadowing the actual trend that followed.
Once Sartor became a practicing physician, she had the opportunity to take care of couples struggling within fertility – a challenge she quickly came to appreciate.
Something else was happening at the time, Sartor said. Knowledge and advancements in reproductive technologies, such as in vitro fertilization (IVF), were soaring. The American Society of Reproductive Medicine was presenting new research during national fertility meetings. Ethical concerns about IVF technology began cropping up in conversations between physicians.
“It was just really exciting,” she said. “We felt like we were on the cutting edge, and we really were.”
The first IVF baby was born in Great Britain in 1978. Three years later, the first IVF baby was born in the U.S. Throughout the 1980s, and into the 1990s, the use of IVF technology and advanced medicines spread to clinics across the country.
A technique called intracytoplasmic injection of sperm (ICSI) was developed in the late 1980s, and allowed fertilization by injecting one sperm into each egg. The first baby born using ICSI to fertilize the egg was in January 1992.
Technology and medicine continued to advance, as did Sartor’s career.
“When I finished fellowship in 1990, the take-home baby rate in IVF cycles per embryo transfer was about 12-percent,” she said. “It is now close to 50-percent, in women age 35 or less.”
Sartor gravitated towards OB-GYN in general, because she knew she would have the ability to care for patients of various ages, and follow them through life. But it is safe to say that her family – her father, in particular – influenced her decision to move in that direction.
Sartor grew up in Clarksdale, Mississippi – a small Delta town in the northwest section of the state. Her mother was a “nurse turned homemaker” and her father was a physician – an OBGYN, as a matter of fact – so she was raised with firsthand knowledge on what it is like to work as a doctor.
“My dad really inspired me,” Sartor said. “He had the discipline, and the devotion, and the ethics to be what I think was a fabulous doctor. So he inspired me, and my mother nurtured me.”
Sartor and her father worked on science projects together, and once saved an injured duck that they discovered in a stream behind their home.
When Sartor began actively pursuing a medical career, she would occasionally shadow her father in the operating room and hospital clinic. Her father once invited Sartor and her then-boyfriend, who was a medical student at the time, to witness and assist a late night delivery. It was a dramatic moment, she said, but not for the reason you’d expect.
“There was this large clatter, as my (boyfriend) fainted,” she recalled. “As he fainted, he took the instrument tray out with him and cut his eyes. And he ended up having to be put on the table and sewed up by my father.”
But aside from delivering babies and suturing former boyfriends, Sartor’s father illustrated the importance of patient care – something she now prioritizes with her own patients.
“It’s not always easy to describe, but it is a very intimate area,” she said. “It’s an intimate way of helping a fellow human being, but there is also an intellectual overlay that satisfies my needs as well.”
For Sartor, the patient-physician relationship begins with listening and education, remaining very clear about the treatment plan, and helping the patient maintain a healthy perspective. But from there, her role slightly varies.
“It’s going to depend on the couple, because everybody that walks through the door brings their own set of personalities, and for some people, pathology,” Sartor said, explaining that the stresses of infertility and the uncertainty of an outcome create an emotionally difficult place for most patients.
“How they negotiate that stress is in part affected by how well myself and my team guide them, and by their own innate emotional fabric,” she said. “A lot of what the patient experiences in the diagnostic and treatment phases places them in a passive position. This can be a very difficult place to be.”
On top of that, the road through infertility treatment is often littered with unexpected setbacks and challenges, she said. The patients that keep their eyes on the future goal, and work with Sartor on solving the problem seem to negotiate these difficulties with less distress.
“What I have found is that some things that make you the most successful in your career attainment – obsessive compulsive tendencies, tremendous work ethic – sometimes make it hard to be a comfortable infertility patient. You are used to driving the train and not being a passenger on it, and so there is always that little bit of tug there,” she said. “I do feel that the patients who are able to take the knocks and the grinds, problem solve, and keep their wits about them, they tend to deal. There are very low lows, and very high highs with this. They tend to make their way through all those peaks and valleys, and reach the prize.”
Solving the problem
Patients are often referred to Sartor by a general OB-GYN. The length of the process to help a patient conceive depends on a number of factors, including the cause of infertility and whether or not the patient has had a “work-up.”
The work-up is a series of tests that help pinpoint what may be responsible for the infertility, and it helps Sartor develop the appropriate treatment plan.
“In order to conceive, a patient has to have open fallopian tubes, has to be ovulating, and has to be partnered with a man with normal semen. The work-up includes assessment of those pieces,” Sartor explained, noting that the tests may be completed within a month.
Following the work-up, nearly ten-percent of couples are deemed to have “infertility of an unknown cause.” If the diagnosis is ovulatory dysfunction, male factor infertility, or mild pelvic factor, such as surgically treated endometriosis, the initial treatment usually involves ovulation enhancement combined with intrauterine insemination. If those approaches don’t succeed, then IVF is used.
The most extraordinary cases involve patients who are considered sterile, pre-IVF, or patients who are born without a uterus – a rarity that occurs in 1 per 4,500 to 5,000 females, said Sartor.
By doing IVF – retrieving eggs and fertilizing them with partner’s sperm – and then transferring the embryo into the uterus of a gestational surrogate, the patient is able to have her own genetically related children.
Other intriguing cases include couples that are at a high-risk for passing debilitating genetic diseases on to their offspring. Sartor explained that IVF with preimplantation genetic diagnosis could help them have healthy babies.
If a woman is facing a cancer treatment that will compromise her ovarian health, oocyte or embryo freezing helps to preserve their future fertility, said Sartor.
“These are the type of cases that really require the assisted reproductive technologies to bring the continued gift of new life,” Sartor said.
“The ability to actually put one sperm into one egg has changed the landscape for couples with male factor infertility,” she added.
If the woman’s partner is paraplegic, and the couple needs help conceiving, an urologist would extract sperm and then fertilize the egg inside a laboratory.
“For me, each patient is special. Each relationship is different. Everybody has a different story,” Sartor said. “When I first meet a patient, I really want to listen. And then my relationship with them will develop. It morphs through time, depending on the needs. But I view my role as part shepherd, shepherding my flock to the desired end, which is a pregnancy. I view myself as a coach. I view myself as an educator, and at times a friend, depending on their comfort level with that.”
The most common cases Sartor manages comprise patients who meet the definition of infertility: they under 35 and have tried to conceive for one year; or they are over 35 and have tried to conceive for six months.
She also meets individuals seeking “fertility preservation” – those who are hoping to save the ability to conceive, “in the face of either aging ovaries,” surgery, chemotherapy, or any type of medical treatment that would harm reproductive organs. Fertility preservation typically calls for IVF.
I’m a lucky woman. I’ve been in a subspecialty that I really love. It has been a gift for me. -Dr. Sartor
Challenges for working women
For women – particularly single women – the largest need for preservation is due to personal reasons, said Sartor. Those personal reasons are often related to pursuing a career. Women may hold off having children, but when they realize they are ready and can afford children, they discover that they don’t have enough eggs to make that happen.
“Reproductive fertility is a very specific arc, and it is not very forgiving,” Sartor said. “So even though women may be trying to attain their career goals, and they look in the mirror and they look young and youthful, their ovaries are on a different path. And so we’re seeing more women who are in the middle of that professional attainment, and worried about what will happen on the other side.”
Sartor said she has noticed a growing use in infertility treatments and egg preservation practices.
According to an article from “Aging,” a peer-reviewed bio-medical journal, the global prevalence of infertility among women, ages 15 to 44, increased by 14.96-percent between 1990 and 2017. The highest increase was in women ages 35 to 40. The numbers vary from country to country, and the reasons for the increase rely on multiple factors.
Referring to the article, Sartor explained that women are waiting a longer amount of time to have their first baby. In the U.S., the average woman waits until she is 26 years old; if she is college-educated, she may wait until she is 32 or 33 years old.
This means that more women are trying to have their first babies towards the end of their reproductive years, said Sartor. But at that point, natural ovarian aging has lowered their ability to conceive. Also, women are more likely experience endometriosis, fibroids, and tubal damage, among other problems.
The increase in egg freezing and the improvement in vitrification – freezing techniques – suggest that the demand for fertility preservation has grown, claims an article in “The New England Journal of Medicine.”
Sartor said even statistics compiled by the Fertility Institute of New Orleans show that the incidence of oocyte freezing for fertility purposes has increased almost 50-percent each year, over the last three years.
“Is the need higher year after year? Or is it that the services that are available to help them are more apparent and more available? I think it’s a little bit of both,” Sartor said. “And, unfortunately the sort of career development in most disciplines, the expectation is that you are going to make your mark when you are in your twenties and thirties. And the expectation is that you are going to have a monkish devotion to that. And you are rewarded if you do, and you are not rewarded if you don’t.”
Sartor believes society needs change its stance on this issue, especially since women are such a major part of the workforce.
“If a woman takes a few years to meet her reproductive goals, she should not be bumped off of the promotion tract,” she said.
As an example, Sartor cited women in academia pursuing positions as tenured professors. They are expected to churn out research publications at an “acceptable rate” over a finite and limited period of time. That period of time occurs when women are most reproductively healthy and should be birthing, if that’s what they choose to do, Sartor explained.
The same is true of women hoping to become partners in a law firm, she said.
“How much you bill and collect depends on in-office time and networking dinners, where you are trying to develop your own clients. All of this takes you away from home and childcare,” Sartor said, adding that if a woman is to become a partner in a law firm, it is usually decided within seven to eight years of her joining the firm – the best time for her, in terms of her ability to procreate.
Women’s professional productivity is often assessed by a committee – a committee mostly comprised of men – who hold the archaic belief that if a woman was truly serious about becoming a member their “club,” she would delay having a child or children, said Sartor.
And although the sharing of home and childcare responsibilities has improved with each generation, much of it still falls solidly on the wife – and the pandemic proved this, Sartor said. Throughout the COVID-19 quarantine, more women than men left their jobs to meet the in-home demands of childcare and virtual learning. This fact backs up the baby bust theory.
The first IVF baby was born in Great Britain.
The first IVF baby was born in the U.S.
The use of IVF technology and advanced medicines spread to clinics across the country.
Number of babies born in the U.S. between 1987-2015 through assisted reproductive technology, according to Society of Assisted Reproductive Technology.
The pandemic affected Sartor’s career in more ways the one.
Back in March of 2020, when it was becoming clear that the novel coronavirus was a deadly and highly contagious pathogen, The Fertility Institute was working with patients who were undergoing or preparing for fertility treatments. Physicians were forced to put them on hold to conserve resources and avoid any procedures or treatments that were not “emergent,” said Sartor.
“We had some patients that we had to disappoint by pulling them back from their treatment protocols. That was difficult for both the patient and the doctor,” said Sartor. “Then in April, we were shut tight as a drum up into the middle of May. But we were doing new patient appointments by June.”
Sartor, like other doctors around the world, pivoted to meeting with patients online.
“In the beginning, there wasn’t a whole lot known about the biology of the virus and best way to treat it, and who is at risk and so on,” Sartor said. “That was developing and evolving in real time, and you are trying to come up with the best advice to give the patient. And so that’s been a little bit difficult.”
The biggest challenge was properly providing infertility care, while simultaneously keeping employees and patients safe and healthy.
Once the clinic reopened, physicians nearly doubled their new patient visits and procedures. The rush of patients continued through October 2020. Doctors also quickly resumed their relationships with patients who had to cancel their appointments in the early spring.
But still, Sartor contracted COVID-19 from a fellow physician.
“On the day that I received my first vaccine, I worked next to a colleague who became symptomatic that evening and then tested positive,” she said. “One week later, I tested negative and felt like I had missed the bullet.”
About twelve days after the exposure, however, Sartor became symptomatic.
“I was lucky because my symptoms were mostly that of a moderately bad flu,” she said. Sartor didn’t experience fever or loose her sense of taste, but she did develop severe headaches, body aches, a runny nose and a cough.
Sartor received the monoclonal antibody-infusion within 24 hours of her diagnosis, which she believes moderated the course of the disease. She returned to work 11 days later.
Now fully recovered, Sartor – when she is not in the office – spends long summer days in Uptown New Orleans. She lives near the Milton Latter Library on St. Charles Avenue, which is an area known for its walkability and easy access to excellent restaurants and shops.
“I love it,” she said. “I can hear the streetcar rumbling by and the noises from the wharf and river. I can hear high school bands practicing for Carnival. I can walk and enjoy the lovely architecture and live oaks and greenery – yet the cultural amenities are minutes away.”
Sartor gardens and spends time with her two dogs – a Jack Russell Terrier and a poodle. Early in the morning, she swims or plays tennis at a nearby club.
“I have to be a tennis substitute because I have egg retrievals (in the morning), so I can’t be dependable with that,” said Sartor. “I kind of come in when they need an additional participant.”
Lately, now that the city has largely reopened, Sartor is enjoying the live music scene. One of her favorite events is the candlelight series, where local musicians perform in gorgeous, intimate venues, such as Felicity Church or Hotel Peter & Paul, while illuminated by electric candlelight.
“We listened to a string quartet one night,” said Sartor, noting that she also attended the reopening of Howlin’ Wolf, which featured the Headhunters.
But medicine has always played a starring role in her life; and it likely always will. Both of her grown children – now in their early thirties – are practicing physicians. One is training to become an OB-GYN. Sartor has been a role model physician for them, just as her father was for her.
But when asked what she values most about her career, Sartor is reluctant to pinpoint a specific element.
“I just like everything – the intimacy with the patient, the bringing to bear my knowledge, and the technical skills that are required,” she said. “I’m a lucky woman. I’ve been in a subspecialty that I really love. It has been a gift for me, and I think I have been able to help many patients.”
In Vitro Fertilization (IVF)
retrieving eggs and fertilizing them with partner’s sperm
Assisted Reproductive Technology (ART)
includes IVF, use of an egg donor, sperm donor or adopted embryo.
Most common cases of infertility Dr. Sartor treats
under 35 and have tried to conceive for one year; or over 35 and have tried to conceive for six months.
26 years old, 33 if college-educated.
Average age a woman has her first baby in the U.S.