Co-written by Stephanie Moss, a 3rd year medical studdent at Rush Medical School, and Dr. Ariela Marshall, a hematologist specializing in disorders of thrombosis and hemostasis in women.
One in eight women, one in four female physicians, and one in two women with endometriosis live with infertility. Although this struggle is incredibly common in our community, we rarely share these experiences with others. This lack of sharing may be because there is so much shame around our bodies’ and not being able to fulfill such a “basic” biological process. Or perhaps because we work in an environment that values time spent on the job versus life at home with a family.
As female physicians, the latter especially hits home. From our pre-medical college years, we are told that if we are to pursue this grueling career we must put our family planning aspirations aside to only focus on our academics. Interestingly, in questionnaires administered in 2020 by the Association of American Medical Colleges (AAMC), only 6.9% of matriculating students, 11.2% of second year students, and 22.6% of graduating medical students reported being legally married. Even fewer of these students reported having one or more dependents (not their partner): 2.4% matriculating, 3.4% in their second year, and 7.4% by graduation. As medical students, we are routinely expected to put our fertility on hold so we can become successful providers who are fully committed to care for our patients. In our personal experience, birth control is often a must for medical students who are married or in a committed relationship, because if we pursue family building we are rarely provided maternity/paternity leave, infertility support, child care, or accommodations to pump breast milk. For the students who do start school with a child or choose to have a child during medical education, it is often their non-medical student partner who carries the responsibility of pregnancy and child care. It is often not until the later years of residency training or early years as an independent practicing physician that conversations about fertility and family planning come to the forefront. Unfortunately, by the time a person planning on carrying a pregnancy gets to this stage in their career, many are in their mid- to late-thirties, an age group that can experience greater risks of infertility, pregnancy, and birth complications.
Every person’s fertility journey is different. Yet, by understanding the process and reading about how different people feel going through this journey, we hope that we can normalize the conversation among the medical community and better support each other. So many people (men, women, nonbinary, and trans people) suffer through infertility in silence, so let’s start by having these crucial conversations—even if it is just with your partner or those close to you. By sharing your aspirations and challenges about fertility, you may receive a sense of solidarity and comfort. We hope to begin a conversation by sharing our own stories: the story of a medical student, Stephanie, who recently went through ovarian stimulation and embryo freezing, and a physician, Dr. Ariela Marshall, who, after years of IVF, was successful in giving birth to a son.
Stephanie Moss’ Journey
After ten years of searching for answers for my chronic abdominal and pelvic pain, I was finally diagnosed with endometriosis in addition to hydrosalpinx and bilateral fallopian tube occlusion (swelling and blockage of both tubes) during my second year of medical school. This diagnosis came via a minimally invasive laparoscopic surgery and a hysterosalpingogram. A hysterosalpingogram is a procedure which externally inserts a tube into the vagina through the cervix and up into the uterus before releasing a contrast fluid. This fluid then spreads to fill up the uterine cavity, through the ovarian tubes (also called Fallopian tubes), and spills out into the abdominal cavity. An x-ray is then used to view a picture of the contrast fluid lining the uterus, fallopian tubes, and into the abdominal area. Any abnormalities are visualized—including, in my case, an absence of fluid spillage into the abdomen (this interprets that the tubes are occluded or blocked, and is also called hydrosalpinx).
The finding that both of my fallopian tubes were obstructed is actually a clinical example of one of the main theories behind endometriosis affecting the fallopian tubes: retrograde menstruation and inflammation induced occlusion (Hill et. al, 2020.) Menstruation products including endometrium-like epithelial and stromal cells in the uterus can grow and expel backwards up through the tubes and sometimes out into the abdominal cavity (Hill et. al, 2020). As the body naturally tries to clean up the area, it induces the immune system through inflammation, which concludes with fibrous scar formation. This scar tissue and inflammation can lead to pain during increased levels of estrogen and progesterone hormones. Individuals who have been found to have tubal endometriosis have been reported to vary between 0.29 to 14.48% (Hill et. al, 2020). However, 60% of individuals with moderate to severe endometriosis, which is described as multi-organ involvement, can have tubal occlusion with endometrial lesions (Hill et.al, 2020).
Now what does that mean for fertility? Ovaries normally release an egg, which then is caught by the finger-like projections of the tube (fimbria) and subsequently roll along the interior of the tube and down into the uterus. If the tubes are clogged, then the egg is not able to travel into the uterus, and stays in the abdominal cavity until it disintegrates. The fallopian tubes are actually not directly connected to the ovary, but are just very close to the ovary. If a person is trying to get pregnant, the sperm usually swims up into one of the tubes from the uterine end to meet the egg. However, if the tubes are clogged, then pregnancy can not occur. Sometimes, the sperm can get past a blockage and meet the egg, however a growing embryo after fertilization cannot—this is one of the causes of ectopic pregnancy, which is a non-viable, maternally life-threatening early pregnancy condition which needs immediate medical attention.
In short, the joy of finally receiving an explanation for my pain through an endometriosis diagnosis quickly became overshadowed by the knowledge that I may not be able to have children via the “natural” route. I was diagnosed with infertility. This diagnosis hit me hard, in a way I never expected. As a trauma survivor, I struggled to articulate my emotions to myself and to others. In reflection, I felt a deep sense of emptiness, despair, and brokenness. How could I, a “healthy” twenty-six year old, be potentially unable to complete the most basic biological process of having a baby? I felt responsible and full of self-hate for my possible failure to bear children by natural means. As a married future doctor, with both my partner and me in medical school and with at least six more years of medical training ahead of us, we knew that having children was not financially nor reasonably possible in the near future.
Overtime I would learn to change my internal self-talk to say: “Infertile does not mean I can’t conceive at all, infertile just means I can’t conceive on my own and I need help from science and medicine.” From my medical knowledge I knew that naturally my ovarian reserve and follicles lessened in number each year as I grew older. Therefore I needed to make a plan to preserve my fertility if I ever wanted to increase the chances that I may have biological children in the future. Fertility preservation, which I soon began, is when patients who aren’t ready and/or able to currently conceive or carry a child can freeze (cryopreserve) eggs or embryos.
The first step before even meeting with an reproductive endocrinologist and fertility specialist was to call my medical school provided health insurance company to determine if fertility treatment was covered under our current plan. To our relief, the majority of the billing codes we provided to the insurance company representative were covered under our PPO plan. Here are the billing codes we provided to our insurance and fertility clinic:
Fertility Testing: (Diagnosis Code: Z31.41) - “no restrictions”
Testing Coverage?(CPT: 76856,76857,74740,76830,76831,58340) - “yes”
Fertility Treatment: (Diagnosis Code(s): N97.9, Z31.83) - “yes, depends on code”
IntrauterineI Insemination (IUI) Coverage?(CPTCode: 58322) - “no”
In Vitro Fertilization (IVF) Coverage? (CPT: 58970,58974) - “yes”
Lifetime or yearly limits for fertility treatments? - “4 per contract year”
Does insurance require prior authorization before treatment begins? - “no”
Infertility medication coverage? - “yes”
Fertility Preservation (Diagnosis Code(s): Z31.62, Z31.84) - unknown
Any exclusions for Egg Retrieval (CPT: 58970) - unknown
Since it seemed that everything on the insurance end was good to go, I began a year-long process of infertility treatment. Blood tests were ordered and all my hormones were checked and monitored to get a baseline starting point. An area of concern was that I had a very low Anti-Müllerian hormone (AMH), a level of 0.96 ng/ml (normal range is: 0.69-13.39 ng/mL) which demonstrated an already declined ovarian reserve. The fertility physician said she preferred to do ovarian stimulation on individuals with an AMH above 1 ng/ml, but would proceed in my case if we did it as soon as possible before it continued to decrease. I began pursuing my first ovarian stimulation cycle that year due to this urgency, which included taking a year off from medical school.
The next hurdle included enduring a long fight to acquire the injectable medications required for ovarian follicle stimulation. For nearly six months I spent hours having back and forth conversations with insurance and a specialty pharmacy. When the pharmacy would bill insurance, only half of my fertility medications were covered. Particularly five injectable medications were not covered under pharmaceutical benefits, because they were not being “injected' by a provider.” These medications were: Lupron (J9217), Ganirelix (SO132), Follistem (SO128), Novarel (JO725), Menopur (SO122). The total out of pocket cost would be over $10,000 for these injectable medications, for just one stimulation cycle. However, these five injectable medications were possibly covered under medical benefits. Therefore, I submitted a prior-authorization, which required more hours of acquiring health records from multiple providers. Unfortunately, this prior authorization was later denied with a reasoning that “infertility medications are not covered under this insurance plan.” Thankfully, after many more months of persistence, my caseworker at the speciality pharmacy was able to get the five injectable medications approved and fully covered under my health insurance.
That fall I went through an ovarian stimulation cycle which included daily injections, and frequent (sometimes daily) blood tests and ultrasounds—notwithstanding that the extreme physical pain from the increased hormones impacted my endometriosis. There are three stages in an ovarian stimulation cycle: suppression, stimulation, and trigger. In some cycles, suppression comes before stimulation, and in some, the medications that cause pituitary suppression happen later in the cycle after stimulation. In patients with endometriosis, some fertility doctors tend to do the suppression stage first, to ideally cause quiescence of endogenous hormones and thus the endometriosis as well.
The overall goal of suppression is to prevent ovulation, which is the release of any egg, in a dominant follicle, from the ovary. Usually the pituitary gland, which is located in the brain, releases both Luteinizing Hormone (LH) and Follicle Stimulating Hormone (FSH) into the blood which travels to the ovaries to tell them to produce the hormones estrogen and progesterone. These hormones work to stimulate the ovary to produce an egg. In individuals who have ovaries, normally once a month there is an accumulation of these hormones (called a surge) which leads to a release (ovulation) of a mature egg. In this suppression stage we prevented the increase of Luteinizing hormone (LH) through daily injections of Leuprolide, which in this continuous style acts as an GnRH antagonist (even though it is actually a GnRH agonist). Ganirelix is a GnRH Antagonist injected each day during this stage. Every 3-4 days in this stage I went to fertility clinic to get blood drawn, my weight checked, and an ultrasound to see that if I did have any follicles (which might contain eggs) that they were less than 10 mm, and that my uterine lining was thin, meaning my ovaries where adequately suppressed. I ended this suppression stage with about four small follicles.
One day in the clinic I was given instructions to start the second stage, stimulation, which would last eight to fourteen days. This stage would add in another round of daily injections to start telling my ovaries to work on overdrive and produce as many follicles as possible. I also learned I was supposed to be taking prenatal vitamins and aspirin to prevent blood clots and anemia. I was so embarrassed that I had not remembered to start taking these over the counter medications, that I ended up breaking down in huge sobs the moment I returned to my car in the student and faculty garage. I had not realized how much I was becoming emotionally overwhelmed with trying to keep track of all these new medications, injections, and protocols all while continuing to study and work. I had no one to call who understood what I was going through. All my friends and family were either students themselves who had never had children, or were people who had easily become pregnant naturally. I wrote in my journal, “Who will listen? Who will care? I don’t want someone to say, I am sorry, or, that sucks, I want to get advice on how to live and get through this. How AM I going to get through this?”
I had no idea that my emotions would only amplify as I began the most grueling, time consuming, and painful process of follicle stimulation. Through injections of FSH and LH, such as Menopur (FSH and LH purified from the urine of menopausal women!) and Follistim (recombinant FSH), my ovaries would increase the number, size, and maturity of follicles. The most significant side effects were weight gain and lower abdominal bloating from the extra fluid in each follicle. These follicles would grow 1-2 mm per day until they are above 15 mm in diameter, with the largest almost 20mm.
It is imperative to note that for those with endometriosis, like myself, one should prepare for a possibly daily painful endometriosis flare and “endo-belly." As more follicles develop and grow, there is crowding in the peritoneal cavity, which may touch and trigger already existing endometriosis adhesions and scars. The stimulated growing follicles also release estrogen which high levels of this hormone further stimulate endometriosis. I was in so much physical pain especially when my estradiol (estrogen) levels reached over 1200 pg/ml (Reference range during a non-hormone induced Mid-cycle is anywhere from 64-357 pg/ml) and left me on bed rest. My doctor had warned me to not do any jumping, twisting of my hips, or any abdominal work to prevent ovarian torsion (a surgical emergency). However, one of my side jobs was a fitness instructor so I had planned to do a very gentle and low key class. After 15 minutes, I almost collapsed in pain. I immediately called my supervisor and said I could not teach until this stimulation cycle was over. I was disheartened that my normal coping strategies of dancing and movement became off limits. I became so bloated that I could only wear dresses because any compression on the stomach caused pain. My doctor was able to eventually decrease some of the pain by lowering the amount of estrogen I was producing. Daily heat packs, baths, and pain meds were a must. Looking back, I wish I had used my chronic-pain management strategies such as a TENs unit, pelvic wand, or had gone to my pelvic floor physical therapist.
Additionally, every clinical visit includes a transvaginal ultrasound, which is commonly painful for people with endometriosis, to confirm the follicles are growing and that the uterine lining is thickening appropriately (although this matters less in egg or embryo freezing cycles). For this procedure I had the advantage of being a medical professional and able to properly coach the ultrasound tech to limit pain and I also took pain medications beforehand. I felt so lonely and physically worn out. The novel science of learning medications and injecting myself multiple times a day became a burden I despised. I felt frustrated that I put myself through this, even though I wasn’t even planning on having children until I finish my medical training in over six years.
Eventually, I hit the perfect ratio of hormones in my body and number of follicles, so I was instructed to begin the third stage. The trigger injection I used was Novarel, (human chorionic gonadotropin/cHCG, also known as pregnancy hormone) which acts like a LH surge, signaling to the ovaries to mature and release the eggs around 36 hours later. At 11:30 PM on Sunday night, my swollen and bruised pin cushion of a stomach received its last doses of injections before Monday’s egg retrieval.
After three weeks of daily injections, I was finally able to get my follicles aspirated and the eggs retrieved. This occurred in an outpatient hospital room under minor anesthesia. My fertility doctor used a special transvaginal ultrasound with a needle to go through the vaginal wall at an angle to go directly to the ovary in the peritoneal cavity. Then each follicle was popped and immediately aspirated, draining all the fluid from each follicle. The surgery took about 20 minutes after I was taken back, and I left with a chaperone (my husband) to drive me home an hour after coming out of the anesthesia. I had a pain level of 5 out of 10, and I was more mobile than I expected, most likely because I had less fluid and more space in my abdomen. The embryologist in the lab then viewed the fluid under a microscope to confirm the number of eggs I had produced. For me, they were able to remove 9 follicles which 5 of them had mature eggs which we planned to freeze, cryopreserve, until we were ready to use them. If no eggs were produced then possibly a second trigger shot would be given.
My doctor highly recommended that we go ahead and fertilize the eggs since they had a greater chance of surviving the freeze and thaw since we were waiting to use them until after our residency training. In conventional laboratory insemination, the highly trained scientist puts tons of sperm next to one egg until a single sperm is able to penetrate the egg and fertilize it. On average, about 60-80% of eggs are able to get fertilized this way. If unsuccessful, if the sperm is not as mobile (male factor infertility), or if a specific sperm is selected for genetic reasons, then intracytoplasmic insemination (ICSI) is done by inserting a specific sperm right into the egg using a needle.
After the sperm penetrates the egg, the combined genetics is called a zygote, which then goes through a series of cell divisions; one large cell becomes two, then four, then eight, and then sixteen cells (called a morula). After about five to six days post insemination, the zygote has divided to become over 60 cells, and has entered the blastocyst stage. This is the stage that the zygote can attach, also called implant, onto the lining of the uterus. For us, we were lucky enough to fertilize all five eggs, but only one zygote was able to complete the blastocyst stage of development, which was then frozen. Unfortunately, this was to be expected, as only 20-40% of inseminated eggs will fully go to the blastocyst stage and be able to be implanted into a uterus to grow into a viable embryo. Learning that we could only freeze one embryo brought on a final wave of emotions including frustration, sadness, anger, self-hate, and a sense of failure. However, over time I became thankful that we were able to create one embryo to freeze, thus all my emotional and physical pain was not fruitless.
Dr. Ariele Marshall’s Journey
When I started my IVF journey, a friend (who had gone through IVF herself) told me: “It’s not for the faint of heart.” There is no way to summarize “briefly” what the process of IVF is like; it’s a process that takes a huge emotional, financial, physical, and social toll. I’m going to try my best to express, in just a few paragraphs, the basics of a process that took a couple of years of my life.
It took my husband and myself months to get embryos—a process that has already been outlined by Stephanie. I’m going to talk about the later steps in the IVF process. Just keep in mind that many people aren’t able to get embryos at all after months or years of trying and thousands of dollars of hormone treatments; the fact that we had embryos at all makes me feel incredibly lucky.
When it’s time to put one of those embryos back into a uterus, the job of IVF treatments is to prepare the uterus and body and essentially “fool” it into thinking that it is pregnant on its own. For women who do a “fresh” transfer (meaning very soon after egg retrieval and embryo creation), fewer hormones are needed because the body is already prepared from the hormones taken for the egg retrieval. However, I did a “frozen” transfer (meaning that our embryos were created earlier and had been stored “on ice”, in a liquid nitrogen tank). The reason we chose to do a frozen transfer was that we wanted to have our embryos tested for any genetic abnormalities, and this testing can only be done with a frozen transfer (the fresh transfer process does not allow time to test embryos before putting them back into the body).
To prepare for the frozen transfer, estrogen pills are given for about a couple of weeks to help thicken the lining of the uterus (to prepare it to be able to support a pregnancy). Ultrasounds are done to monitor how thick the uterus lining is and estrogen is continued until the uterus is thick enough to support a pregnancy. If the uterus lining does not increase in thickness, sometimes estrogen is given for longer or the dose is increased. Unfortunately, some uterine linings never get to the thickness they need to be even with lots of estrogen, and the transfer process cannot continue. Thankfully, in my case, my uterus lining grew like it was supposed to with the estrogen pills and as soon as multiple ultrasounds showed the lining was as thick as it needed to be, I got a “transfer date” (a date when the embryo would be transferred back to my uterus).
Before the embryo transfer, I needed to start progesterone treatments (in addition to the estrogen pills). Progesterone can be given a couple of ways: through shots (intramuscular injections), vaginal suppositories (tablets inserted into the vagina), pills, and now even subcutaneous (under the skin) injections (although subcutaneous injections were not an option at the time that I went through IVF). There is a high amount of debate concerning which type of progesterone administration is best, but it’s generally believed that pills are not as good as shots/suppositories. There are several medical studies on different “regimens” for progesterone and at the end of the day many reproductive endocrinologists recommend either once-daily progesterone shots or every-three-day progesterone shots plus twice-daily progesterone suppositories.
There are pros and cons to both options, but at the end of the day, and for me, I went with the every-three-day shots plus twice-daily suppositories because these shots hurt. They hurt a lot, because not only are the needles pretty big, but the progesterone is actually prepared in oil, which is thick and means that it takes a longer time to go in once the needle is inserted in the body. I came up with my own little routine for the shots which involved applying a heating pack before (to loosen up the muscle), then having my husband (God bless him!) give me the shot, pound on my muscle with karate-chop motions afterward to distribute the oil so I didn’t get a “lump” of oil, and then roll the area with a rolling pin. The progesterone suppositories were not fun either: they were easy to insert (they came with an applicator like a tampon) but unfortunately led to a cottage-cheese like vaginal discharge so I had to wear a pad every day for weeks.
The progesterone shots and pills are continued through the transfer. On transfer day itself, the process is actually pretty quick. I went into the procedure area, had my vitals taken, was taken back to the room, and then got to watch as they inserted a speculum and did an ultrasound to look at the uterus, then inserted a skinny plastic tube. Into that, they put another (smaller) tube that actually had my embryo. I actually saw it as it went in! That was pretty amazing. The whole thing took about ten minutes maximum, and then I got to stand up and walk out.
I will say that I went through this twice, because the first transfer did not work. There’s no rhyme or reason to it, and no explanation for why the first one didn’t work and the second one did. Even when an embryo is good quality and chromosomally normal (“euploid”) the success rate is still 60-70% and not 100%. I also want to mention that women are generally given the option of taking a mild sedative (valium) before the transfer to help them relax. I did this for my first transfer and by the time the procedure was done I was pretty zonked out and had to go home and sleep the rest of the day. For the second transfer, I wanted to remember and experience exactly what I was going through and be at my full mental capacity as I watched it happen (how many people can say they actually watched the moment of conception of their child?! That’s an actual bright side of IVF)… so I did not choose to take the sedative. I actually met with my mentor right after the transfer (she’s an amazing woman who went through IVF twice herself, and she said a blessing for the transfer to work, which I swear may have been what made the second time successful)—but then I went back to work later that day to take my mind off things.
The thing with transfer is—you don’t know for over a week if it worked. You do the transfer process, continue the estrogen and progesterone medications on the same schedule, and just wait. Many days (what feels like an eternity!) later, you go in for a pregnancy test. The first time I did the transfer, it was negative, so when I went in the second time, I had a lot of anxiety about “what if this one didn’t work either?” As a doctor I had access to my own medical chart and get results pretty quickly, so when I saw that the result was in, I actually closed my eyes and held my breath for a while before looking at it. When I saw it was positive, I didn’t believe it. I actually told my husband, “I don’t believe this.” But it was positive!
That’s not the end of the monitoring. You have to continue to go through tests to check that the level of the pregnancy marker (HCG) is rising the right amount, and at 6 weeks you go in for an ultrasound to confirm a heartbeat. Every single test I did was influenced by my prior struggles and I was so anxious and somehow convinced it wouldn’t work. The feeling of hearing “congratulations” at the 6-week ultrasound was not even as much a “happy” feeling for me as it was a huge relief. The estrogen and progesterone are continued for a couple more weeks after that and during this time I had a couple of episodes of bleeding from the vagina—probably related to the trauma of applying the suppositories twice a day for many weeks but each time it happened I was convinced that I had lost the pregnancy. I went in for not one but two extra ultrasounds and I’m a person that generally avoids any medical tests that aren’t absolutely necessary. Every time, that huge feeling of relief struck me.
And around 9-10 weeks into the pregnancy, you are told you can stop the hormones. I was again terrified—did my body really know it was pregnant when everything before that had been “fake” hormones given through shots, pills, and suppositories? Was it safe to stop them and trust that my body would take over on its own? Of course I did what the reproductive endocrinologist recommended and in the end it turned out just fine—the body is really an amazing thing.
I was blessed that the rest of my pregnancy was relatively uncomplicated (until delivery, but that’s a story for another day). Yet it was still overshadowed by my anxiety and pervasive thoughts of, “is this really happening? Can this actually be going like it is supposed to?” The extra degree of anxiety and stress is really normal for women going through IVF since we have already been through so much. My husband was amazing and we celebrated every single week of the pregnancy—he actually got me a new bouquet of flowers for every week as the pregnancy advanced, and this was a milestone celebration that had so much meaning for us. There were a couple of very specific milestone weeks that we celebrated even more (24 weeks, when the odds of viability start to increase significantly, and then 37 weeks, when if I went into labor it would no longer be considered preterm).
As data suggests, 1 in 2 women with endometriosis and 1 in 4 female physicians will experience infertility. That’s twice the rate of the general population, which is 1 in 8 women. The reasons for the increase in infertility for female physicians include significant stress levels during the education and profession, differed family planning, and long hours of medical careers. Black and Hispanic women have even higher risks of experiencing infertility rooted not in biological differences but due to social inequalities and disparities in health. Everyone should have the chance to choose if and when they are able to have a child, and financial barriers shouldn’t be another limiting factor. Very few states in the US are starting to require companies to provide comprehensive fertility coverage in health care insurance, one of the few exceptions being the Illinois Mandate. Unfortunately, fertility health insurance coverage must radically improve in order for all individuals who need care to receive fertility testing, treatment, and support. If you are struggling with infertility, know that you are not alone. Only by sharing our struggles with others will we be able to conquer this journey together. We do not need to be silent any more.
Stephanie Moss is an endometriosis and infertility warrior, a rrauma survivor, an trauma-informed healthcare advocate, and a 3rd year Medical Student pursuing her Medical Doctorate (M.D.) at Rush Medical College in Chicago. She has a lifelong passion for health equity and serving individuals who are disenfranchised by society. She is currently a part of Family Medicine Leadership Program (FMLP), American Medical Women's Association (AMWA) Infertility Committee, and is one of the co-founders of Chicago Homelessness and Health Response Group for Equity (CHHRGE). She loves to speak on her passions and share her experiences being a Latina medical student with a history of trauma, mental and physical illness. Her work has been featured across various platforms including The Endometriosis Foundation, KevinMD, Doximity, American Medical Women’s Association, Illinois Academy of Family Medicine Physicians, and Survivor Revivew. She has also created a website medpsycmoss.com which features her blog, links to her work, and a comprehensive selection of trauma-informed resources for both patients and health care providers.
Dr. Marshall is a hematologist specializing in disorders of thrombosis and hemostasis in women. She is a graduate of Harvard Medical School and completed her residency in Internal Medicine at the University of Pennsylvania followed by a fellowship in hematology-oncology at Dana Farber Cancer Institute/Massachusetts General Hospital. She worked at Mayo Clinic in Rochester Minnesota from 2015-2021 and recently joined the faculty at University of Pennsylvania in Philadelphia, Pennsylvania where she is the Director of the Women’s Thrombosis and Hemostasis program. Dr. Marshall is a medical educator with a focus on career development, leadership, and mentorship and serves as the Associate Program Director for the Benign Hematology Fellowship at University of Pennsylvania. She has a particular interest in gender equity in medicine and leads several research projects and advocacy initiatives to advance efforts in fertility/infertility awareness, parental health, and gender equity for women in medicine nationwide. In addition to her career, Dr. Marshall also places great importance on her family including her husband Suraj and son Rivaan, and enjoys travelling, dance, and foodie culture.
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