Exploring The Spectrum of Pregnancy Complications Amongst Operating Room Personnel: Multidisciplinary Review

This comprehensive review synthesizes findings from studies conducted between November 2000 and December 2023, focusing on the reproductive health challenges faced by operation room personnel. Data from electronic databases, including PubMed, Embase, and Cochrane Library, were analyzed using a combination of keywords related to occupational hazards, fertility, and pregnancy. Inclusion criteria encompassed studies in English exploring fertility and pregnancy-related factors in operation room personnel. The synthesis of findings reveals several critical themes.

Exposure to anesthetic gases, such as nitrous oxide and halogenated agents, presents potential risks, with associations to adverse reproductive outcomes identified in numerous studies. Radiation exposure, primarily from surgical and radiological procedures, also poses risks to fertility. Chemical exposures, shift work, physical strain, and ergonomic factors further contribute to the multifaceted landscape of reproductive challenges faced by operation room personnel. Mental health and stress management, age-related considerations, and infections due to occupational exposure are additional dimensions explored in this review. the studies emphasize the importance of workplace policies and support structures. Inconsistent maternity leave policies, financial barriers, and a lack of inclusivity contribute to challenges faced by female surgeons. The review underscores the need for equitable and inclusive environments, formal maternity policies, and a shift in surgical culture. Fertility preservation options, workplace policies supporting work-life balance, and access to comprehensive reproductive health education are highlighted as crucial components. The review concludes by advocating for a holistic and collaborative approach to address the reproductive health and well-being of operation room personnel. The findings stress the importance of creating environments that safeguard the health of healthcare professionals and enable them to navigate the complexities of family planning and parenthood while pursuing fulfilling careers in the surgical field.

Pregnancy complications represent a complex and multifaceted aspect of maternal health, requiring a nuanced understanding, especially among individuals who work in high-stress environments such as operating rooms. The intersection of maternal well-being and occupational demands has garnered increased attention within the healthcare community. As medical professionals strive to balance their dedication to patient care with the physiological demands of pregnancy, it becomes imperative to explore the specific challenges faced by those working in the dynamic and critical setting of the operating room [1].

The operating room, characterized by its fast-paced and often intense nature, poses unique occupational hazards that may influence the course of pregnancy for individuals directly engaged in surgical procedures and ancillary support roles. While existing literature has extensively addressed the broader landscape of pregnancy complications, a comprehensive analysis specific to the distinctive challenges encountered by operating room personnel remains relatively underexplored 

Irregular Work Schedules: Operation room personnel, especially surgeons and anesthesiologists, often work long and irregular hours. Irregular work schedules may impact lifestyle factors, such as sleep patterns and stress levels, which can influence fertility. Exposure to Occupational Hazards: Some studies suggest that exposure to certain occupational hazards, such as radiation, anesthetic gases, and certain chemicals used in healthcare settings, may have potential effects on fertility. However, strict safety measures and protocols are in place to minimize such risks. Stress and Job Demands: The high-stress nature of work in the operation room, coupled with demanding job responsibilities, can contribute to increased stress levels. Chronic stress may affect fertility and reproductive health [2]. Physical Strain: The physically demanding nature of surgical work, including long periods of standing and performing precise movements, may contribute to physical strain. While not directly linked to fertility issues, physical strain can impact overall health, including reproductive health. Age and Career Advancement: Individuals in operation room roles often pursue advanced education and training, which may extend the duration of their education and delay family planning. Delayed childbearing, especially for women, can be associated with increased fertility challenges. For example, for surgeons as one the primary structure of ant operation room with a growing number of women entering the surgical profession, comprising 38% of residents and 21% of practicing surgeons in the US, challenges persist for female surgeons in balancing work and family responsibilities [3]. Early in their careers, female surgical residents face issues such as pregnancy-related stigma, unmodified work schedules during pregnancy, limited and often brief maternity leave options (typically 6 weeks or shorter), and inadequate support for childcare and lactation needs post-delivery [4]. Consequently, many female surgeons opt to postpone starting a family until after completing their training, coinciding with the diagnosis of advanced maternal age at 35, where risks of infertility and adverse pregnancy outcomes significantly increase. Despite their increasing numbers, female surgeons are more likely to be childless compared to their male counterparts, yet little is known about the specific risks of infertility and pregnancy complications for this group [5]. Shift Work and Circadian Rhythm Disruption: Shift work, common in healthcare professions, can disrupt circadian rhythms. Disruptions in the natural sleep-wake cycle may affect hormonal regulation and, in turn, fertility. Exposure to Infections: Healthcare professionals, including those in the operation room, may be exposed to various infections. While not directly related to fertility, certain infections can have implications for pregnancy planning and maternal health [6].

Exposure to Anesthetic Gases: Some studies have explored the potential impact of exposure to anesthetic gases on fertility. While there is ongoing research in this area, adherence to safety guidelines and protocols, including proper ventilation systems and the use of scavenging devices, is crucial to minimize any potential risks. Reproductive Health Education and Counseling: Operation room personnel, like anyone planning a family, can benefit from reproductive health education and counseling. Understanding the potential challenges associated with their profession and learning about family planning options can empower individuals to make informed decisions [7]. Supportive Workplace Policies: Supportive workplace policies, such as those providing adequate maternity and paternity leave, flexible schedules, and accommodations for family planning, can positively impact the work-life balance of operation room personnel. These policies contribute to the overall well-being of individuals seeking to balance their professional and family responsibilities. Infertility Treatments and Assisted Reproductive Technologies (ART): Individuals facing fertility challenges, including those in operation room roles, may explore fertility treatments such as in vitro fertilization (IVF) or other ART options. Access to these treatments and the emotional support provided by the workplace can be important considerations [8]. Preconception Health: Just as with any individuals planning a pregnancy, maintaining good preconception health is crucial. This includes a balanced diet, regular exercise, avoiding harmful substances, and managing stress. Operation room personnel should prioritize their overall well-being to support reproductive health. Age-Related Considerations: Age can impact fertility, and women in particular may face biological factors related to fertility decline with age. Operation room personnel, especially those pursuing advanced education and training early in their careers, may want to consider family planning timelines in light of these biological factors [9]. It's important to emphasize that the impact of these factors can vary widely among individuals. Additionally, many operation room personnel successfully navigate their careers while building families. Personal choices, overall health, and lifestyle factors play significant roles in fertility and pregnancy outcomes considerations regarding fertility, pregnancy, and the workplace environment for operation room personnel:

Workplace Culture and Support: A positive and supportive workplace culture can significantly impact the well-being of operation room personnel. A culture that values work-life balance, family planning, and provides resources for reproductive health can contribute to a healthier and more satisfying professional experience. Mental Health and Coping Strategies: The demanding nature of work in the operation room can sometimes contribute to high levels of stress and emotional strain. Maintaining good mental health is essential for overall well-being, including reproductive health. Coping strategies, such as counseling, mindfulness, and stress management techniques, can be beneficial. Occupational Exposure Monitoring: Healthcare facilities often have protocols in place to monitor and minimize occupational exposures to potential hazards. Operation room personnel should be aware of these protocols and actively participate in monitoring efforts to ensure a safe working environment [10]. Planning and Communication with Supervisors: Clear communication with supervisors regarding family planning intentions can be beneficial. This can help in the coordination of work schedules, especially during times of planned family expansion, and may allow for more flexible arrangements when needed. Educational Resources: Providing operation room personnel with educational resources on reproductive health, family planning, and the potential impact of occupational factors can empower individuals to make informed decisions. Workplaces can offer seminars, workshops, or access to educational materials to raise awareness. Community and Peer Support: Establishing a supportive community within the workplace, where colleagues can openly discuss and share experiences related to family planning and reproductive health, can create a positive and inclusive environment. Peer support can be particularly valuable in navigating shared challenges [11].

Fertility Preservation Options: In cases where individuals anticipate delays in family planning due to career demands, considering fertility preservation options, such as egg or sperm freezing, may be a proactive choice. This allows individuals to preserve reproductive material for future use [12].

This narrative review endeavors to fill this critical gap by synthesizing existing research and shedding light on the intricacies of pregnancy complications among individuals working in the operating room. By delving into the available body of knowledge, we aim to provide a thorough examination of the types, prevalence, and risk factors associated with pregnancy complications in this specialized occupational setting. Moreover, this exploration will extend to the identification of preventive measures and interventions that can be employed to safeguard the well-being of both the expectant mother and the developing fetus. Understanding the intricacies of maternal challenges in the unique context of the operating room is not only essential for the health and safety of healthcare professionals but also holds broader implications for healthcare policies, occupational health practices, and the overall well-being of those committed to delivering quality patient care. This review aspires to contribute to the ongoing discourse surrounding maternal health in high-stakes environments, providing insights that can inform future research directions and promote evidence-based strategies to support pregnant individuals in the operating room.

For data gathering, a comprehensive search of electronic databases, including PubMed, Embase, and Cochrane Library, was conducted. The search strategy employed a combination of keywords related to, Operation Room Personnel, Occupational Hazards, Fertility, Pregnancy, Anesthetic Gases, Radiation Exposure, Chemical Exposure, Shift Work, Physical Strain, Mental Health, Age-Related Factors, Fertility Preservation, Workplace Policies, Reproductive Health Education, Social Support, Ethical Considerations, Professional Development, Access to Reproductive Healthcare, Research and Advocacy, Family-Friendly Policies and selected studies were thoroughly studied and finalized. The inclusion criteria encompassed studies published between November 2000 and December 2023, written in English, and involving fertility and pregnancy-related factors in operation room personnel. Randomized controlled trials, prospective and retrospective cohort studies, as well as systematic reviews and meta-analyses were included. The identified studies were screened based on title and abstract, followed by full-text review to assess their relevance to the topic.

Findings:

Operation room personnel, encompassing surgeons, anesthesiologists, and other healthcare professionals, may encounter occupational exposures and risk factors that warrant attention in the context of fertility and pregnancy. While research is ongoing and evidence may not be conclusive, several specific factors have been identified:

1. Exposure to Anesthetic Gases:

Anesthesia personnel, including anesthesiologists and nurse anesthetists, face potential exposure to trace amounts of anesthetic gases during procedures. Agents such as nitrous oxide, halogenated agents (e.g., sevoflurane, desflurane), and volatile agents are commonly used. Some studies have suggested associations between occupational exposure to anesthetic gases and adverse reproductive outcomes, including an increased risk of spontaneous abortion and congenital abnormalities. The study on congenital anomalies and inhalation anesthetics, conducted by D.A. Bussard, revealed that nitrous oxide and halothane, either alone or in combination, demonstrated the potential to induce congenital anomalies and increase fetal death rates in experimental animals. Epidemiological investigations involving pregnant operating room personnel exposed to trace amounts of these anesthetics indicated a higher incidence of miscarriages compared to non-exposed counterparts. Dental personnel, exposed to even greater concentrations of nitrous oxide, faced an elevated risk. Despite this, further extensive studies are deemed essential for a comprehensive understanding. In light of these findings, dentists, particularly when dealing with pregnant patients in the first trimester, bear a primary responsibility to carefully consider the use of inhalation anesthetics. This caution extends to the potential risk for pregnant dentists and assistants [13]. Another study on the embryotoxic/teratogenic potential of halothane, conducted by C. Baeder and M. Albrecht, assessed available data through an extensive literature search. Halothane was found to induce ultrastructural visible changes in the offspring of rats exposed to concentrations of 10 ppm during gestation. These changes included degenerative alterations in the cerebral cortex, weakening of cell membranes, and vacuolization of the Golgi complex. Macroscopically visible morphological changes in rats occurred only after exposure to concentrations equivalent to 320-fold (1600 ppm) the MAK value (maximum concentration value at the workplace). Behavioral disorders were observed in rats when exposed to concentrations greater than or equal to 10 ppm during gestation and after parturition. In mice, macroscopical investigations showed disturbances, visible as retardation in the offspring, occurring after exposure to concentrations of halothane 200-fold (1000 ppm) the MAK-value. However, in rabbits, exposure to anesthetic concentrations of 22,000 ppm halothane did not result in embryotoxic/teratogenic effects. Controversial discussions surround individual epidemiological findings in humans. The studies are inconclusive in establishing an embryotoxic/teratogenic risk following sole exposure to halothane at the MAK level due to mixed exposures and missing data on halothane concentrations in the inhaled air [14]. Also, In the study conducted by E.N. Cohen and colleagues, a mail survey involving dentists and chairside assistants examined the occupational disease in dentistry and chronic exposure to trace anesthetic gases. Findings indicated increased general health problems and reproductive difficulties among respondents exposed to anesthetics. Male dentists with heavy exposure showed elevated rates of liver, kidney, and neurological diseases. Wives of male dentists with heavy exposure had a higher spontaneous abortion rate. Female chairside assistants with heavy exposure exhibited increased rates of liver, kidney, and neurological diseases, along with a higher spontaneous abortion rate. The study also highlighted the association of chronic exposure to nitrous oxide alone with an increased rate of adverse responses in both dentists and chairside assistants [15]. by the way the meta-analysis by JF Boivin investigates the association between maternal occupational exposure to anaesthetic gases and the risk of spontaneous abortion. The study collected data from published epidemiological studies identified through literature reviews, reference list perusal, and Medline searches. The analysis included 24 comparisons between exposed and unexposed women, obtained from 19 reports. The overall relative risk of spontaneous abortion associated with occupational exposure to anaesthetic gases was estimated at 1.48 (95% confidence interval (95% CI), 1.4 to 1.58). To assess the impact of study quality on this result, the validity of the papers was rated based on criteria such as appropriateness of the unexposed comparison group, control for non-occupational confounding variables, and response rate. When the analysis was restricted to the six comparisons rated as the most rigorous, the estimated risk increased to 1.9 (95% CI, 1.72 to 2.09). This suggests that the increased risk of spontaneous abortion associated with occupational exposure to anaesthetic gases was not diminished but rather intensified when considering the more methodologically sound studies. In conclusion, epidemiological studies, particularly those conducted in the prescavenging era, indicate a heightened risk of spontaneous abortion among women occupationally exposed to anaesthetic gases. The meta-analysis underscores the importance of considering study quality when evaluating these associations, emphasizing a more robust risk estimate in studies with rigorous methodologies [17] study, conducted by J. F. Haas and D. Schottenfeld, explores the potential risks to the offspring of workers exposed to occupational chemical agents with mutagenic, teratogenic, or carcinogenic properties. The review aims to assess evidence for adverse outcomes in pregnancies and hazards to the offspring among working populations exposed to various industrial agents. One well-documented example highlighted in the study is the increased rates of spontaneous abortion among female operating room personnel exposed to waste anesthetic gases during the first trimester of pregnancy. The paper reviews evidence concerning parental occupational exposure to specific agents such as vinyl chloride, benzene, chloroprene, radiation, and petroleum-derived hydrocarbons. The study emphasizes the limited evidence available for hazards to offspring resulting from parental occupational exposures. It also stresses the importance of considering other environmental and behavioral factors, such as smoking, alcohol, and drug exposures, that could significantly impact pregnancy outcomes. The authors outline an approach to surveillance for chromosomal abnormalities in the offspring of occupationally exposed parents, highlighting the need for a comprehensive investigation into the role of occupational and non-occupational factors in shaping the health outcomes of the offspring [17].

2. Radiation Exposure:

Personnel involved in surgical and radiological procedures, such as surgeons and radiologists, may be exposed to ionizing radiation, primarily through X-rays and fluoroscopy. Prolonged exposure to high levels of ionizing radiation has been associated with potential risks to fertility and adverse pregnancy outcomes, including congenital malformations and developmental issues. 

his study by Venita Chandra et al. addresses the unique concern of radiation exposure for vascular surgeons and trainees engaged in increased endovascular practice. Focusing on the safety of childbearing for women in vascular surgery, the multi-institutional study aimed to assess the radiation dosages recorded on fetal dosimeter badges compared to external badges worn by the same cohort of women. Conducting the study from 2008 to 2011, 81 women declared pregnancy, and 32 had regular radiation exposure during pregnancy. Both maternal (external) and fetal monitor dosimeter readings were analyzed. Results indicated that maternal whole-body exposures ranged from 21-731 mrem. Surprisingly, the average fetal dosimeter recordings for the cohort rounded to zero. Only two women had positive fetal dosimeter recordings, with minimal exposures of 3 mrem and 7 mrem, respectively. Importantly, there was no significant difference in maternal exposures before, during, and after pregnancy. The study's conclusion suggests that concerns about fetal radiation exposure, which have led some vascular surgeons to wear double lead aprons during pregnancy, may be unwarranted. The negligible radiation exposure recorded on fetal monitoring, coupled with appropriate safety precautions, challenges the notion that this aspect should deter women from pursuing careers in vascular surgery [18].

3. Chemical Exposure:

The use of various chemicals in cleaning, sterilization, and medical processes introduces potential risks for operation room personnel. Disinfectants, sterilizing agents, and cleaning chemicals are common sources of exposure. Studies have explored the impact of occupational exposure to certain chemicals, with reported associations to menstrual irregularities and reduced fertility in some cases. Studies reveal increased rates of spontaneous abortion, preterm delivery, growth restriction, and congenital abnormalities in female surgeons. While attention has centered on age and demanding working conditions as contributors, this review explores specific reproductive hazards present in the operating room, including radiation, surgical smoke, working conditions, sharps injury, anesthetic gases, and intraoperative use of toxic agents [19].

4. Shift Work and Circadian Rhythm Disruption:

Operation room personnel often work irregular and overnight shifts, potentially disrupting the circadian rhythm. Altered sleep patterns and exposure to light during non-traditional hours may contribute to hormonal imbalances and menstrual irregularities, affecting fertility. Rangel and colleagues aimed to describe the incidence of infertility and pregnancy complications among female surgeons in the US. The study also sought to identify workplace factors associated with increased risk compared with a sociodemographically similar nonsurgeon population. The study included 692 female and 158 male surgeons, and the results revealed that 42.0% of female surgeons had experienced a pregnancy loss, more than twice the rate of the general population. Female surgeons had fewer children, were more likely to delay having children due to surgical training, and were more likely to use assisted reproductive technology compared to male surgeons. Major pregnancy complications were more common among female surgeons compared to female nonsurgeon partners, and this remained significant after controlling for various factors. Female surgeons operating 12 or more hours per week during the last trimester of pregnancy were at a higher risk of major pregnancy complications. Female surgeons were also more likely to experience musculoskeletal disorders, nonelective cesarean delivery, and postpartum depression compared to female nonsurgeon partners. The study highlighted the increased medical risks of infertility and pregnancy complications among female surgeons and emphasized the need for changes in surgical culture to better support pregnancy and reduce the associated risks [20]. also, a systematic review and meta-analysis aimed to elucidate the impact of shift work and extended working hours during pregnancy on maternal and fetal health outcomes. Drawing from 62 observational studies encompassing 196,989 women, the evidence suggested that engaging in rotating shifts was associated with increased odds of preterm delivery, infants small for gestational age, preeclampsia, and gestational hypertension compared to those on fixed day shifts. Similarly, working fixed night shifts correlated with higher odds of preterm delivery and miscarriage. Longer working hours (>40 hours per week) were linked to increased odds of miscarriage, preterm delivery, infants with low birthweight, and infants small for gestational age. Dose-response analysis indicated that women working over 55.5 hours per week faced a 10% rise in the odds of preterm delivery. The findings underscore the elevated risk of adverse pregnancy outcomes for pregnant women engaged in shift work or prolonged working hours [21].

5. Physical Strain and Ergonomics:

The demanding nature of surgical work exposes personnel to physical strain, including prolonged standing, awkward postures, and repetitive motions. While not directly linked to fertility, physical strain and ergonomic factors can contribute to overall health issues, including musculoskeletal problems. The study conducted by M. Estryn-Béhar and colleagues, focusing on the working conditions of operating room personnel, observed that neuropsychological symptoms and tiredness were more frequently reported by workers in less often scavenged theatres compared to controls. Additionally, the study found a higher rate of spontaneous abortions among pregnancies in which women were working in operating theatres. The findings suggest a potential association between working conditions, neuropsychological symptoms, and pregnancy outcomes among operating room personnel [22].

6. Infections and Occupational Exposure:

Healthcare workers, including those in the operation room, may face exposure to infectious agents, including bloodborne and airborne pathogens. While primarily a concern for personal health, certain infections can have implications for pregnancy. Strict adherence to infection control measures is crucial to mitigate these risks. Mitigating measures, such as adherence to safety protocols, proper ventilation, and the use of personal protective equipment, are implemented in healthcare settings to minimize these risks. Ongoing research contributes to refining our understanding of potential hazards and risk factors for operation room personnel. Individuals in these roles should engage in conversations with occupational health professionals and healthcare providers to ensure a safe working environment and address any concerns about fertility and pregnancy [23].

7. Mental Health and Stress Management:

The high-stress environment of the operation room can have significant implications for mental health, potentially impacting fertility. Chronic stress may disrupt hormonal balance and menstrual regularity. Operation room personnel should prioritize mental well-being through stress management strategies, access to counseling services, and fostering a supportive workplace culture that recognizes and addresses the challenges associated with their roles. Natalia Dowgiałło-Gornowicz et al. aimed to explore the perceptions of patients and doctors regarding the professional activity of pregnant surgeons (PS). In the study involving 1074 doctors and 657 patients, respondents provided insights through a 12-question questionnaire. Results indicated that doctors, especially those outside the surgical field, were more inclined to believe that PS should cease working in the operating theatre immediately after confirming pregnancy. Patients, in contrast, viewed operations performed by PS as normal, while doctors were more divided, often perceiving it as either heroic or irresponsible. Concerns about financial stability and fears of reputational loss were more frequently cited by doctors as reasons against PS working. Interestingly, most respondents, with patients notably more vocal, expressed the opinion that it made no significant difference whether they were operated on by PS or not. Conclusively, the study suggests that while female surgeons may harbor slight concerns about perceptions from colleagues and patients, the majority, particularly patients, believe that working during pregnancy is a natural aspect of the surgical profession [24].

8. Age-Related Considerations:

Healthcare professionals, including operation room personnel, often pursue advanced education and training early in their careers. Delayed family planning due to career demands can intersect with age-related declines in fertility, particularly for women. Operation room personnel should be aware of the potential impact of age on fertility and consider family planning options that align with their personal and professional goals.

In the review on occupational reproductive hazards for female surgeons in the operating room, Matilda Anderson and Rose H. Goldman highlighted the importance of identifying and controlling hazards to minimize risks. Studies comparing female surgeons with the general population revealed higher rates of infertility and pregnancy complications, including spontaneous abortion, preterm delivery, growth restriction, and congenital abnormalities. While attention has been given to the older age and demanding working conditions of pregnant surgeons, the review emphasized the presence of reproductive hazards in the operating room, such as radiation, surgical smoke, working conditions, sharps injury, anesthetic gases, and intraoperative use of toxic agents. The available evidence, often limited to retrospective studies, makes it challenging to establish specific dose-response relationships and occupational safety guidelines. Despite this, regulatory agencies have set exposure limits for some agents based on the limited evidence. The review suggested that various workplace interventions have been successful in reducing exposure levels for many reproductive hazards and recommended their adoption in surgical workplaces. It concluded that providing information and guidance to female surgeons of reproductive age and implementing efforts to control exposures are crucial, without unnecessarily restricting the activities of female surgeons [19].

In their systematic review published in Academic Medicine in 2020, AR Todd, TR Cawthorn, and C Temple-Oberle aimed to examine common themes and synthesize data surrounding pregnancy and parenthood during surgical residency training. The review included articles published from 2003 to 2018, focusing on pregnancy, parenthood, and the experiences of surgical residents. Among the key findings, female surgical residents had fewer children during residency training compared to their male counterparts. They tended to have their first child later in life and had fewer children overall compared to the general population. The review also highlighted higher rates of infertility and assisted reproductive technology use among female surgeons compared to the general population. Pregnant surgical residents experienced a high rate of obstetric complications, with predictors including working more than 6 overnight call shifts per month or 60 hours per week. Despite similar academic outcomes, the review identified negative attitudes and perceptions towards pregnancy during residency. The authors concluded that female surgical residents face high rates of infertility, obstetric complications, and encounter negative attitudes and stigma during pregnancy. They recommended the need for formal maternity policies, a shift in surgical culture, and ongoing discussions with all stakeholders to attract and retain female surgical residents [25].

In response to the growing presence of women in urology, the study aimed to evaluate childbearing disparities between female urologists and the general population. Conducted through an anonymous 114-item survey sent to all 365 American board-certified female urologists in 2007, the findings were compared with 2004 CDC data. The results, based on a 69% response rate (n = 243), revealed that women urologists tend to have children later in life, a smaller number of children, and a higher induction rate. Notably, assisted reproduction technology births were nearly ten times more likely among female urologists. The study also highlighted a higher prevalence of pregnancy complications, exceeding rates observed in the lowest income brackets in the United States. Contrary to expectations, cesarean delivery rates were similar. To mitigate complications, the study suggests avoiding delayed childbearing, emphasizing the need for supportive programs in residency and practice groups to accommodate the growing number of women in urology [26].

Also, in investigating the impact of a surgical career on childbearing and fertility among female surgeons, the study aimed to discern differences across specialties. Elevated pregnancy complication rates and increased use of assisted reproductive technology (ART) observed in certain surgical fields prompted an exploration of these trends among female surgeons in various specialties. The survey, distributed to female surgeons in specialties such as general surgery, gynecology, neurosurgery, and others, garnered responses from 1,021 participants. The findings revealed that 32% of women surgeons reported fertility difficulty, with 84% undergoing infertility workup. Notably, 76% of those facing fertility challenges turned to ART for pregnancy attempts, a stark contrast to the 10.9% infertility rate reported by women in the general US population. Female surgeons exhibited a lower-than-average birth rate, having 1.4 biological children, and their age at first pregnancy was notably later at 33 years compared to the national average of 23. Moreover, significant variations in infertility rates were observed across specialties, with otolaryngology (29%), general surgery (22%), and orthopedics (18%) reporting the highest rates. These findings underscore the need for further investigation into the specific impacts of a surgical career on childbearing and fertility in diverse medical fields [27].

9. Fertility Preservation Options:

For individuals facing the prospect of delayed family planning due to career advancement, fertility preservation options such as egg or sperm freezing can be proactive choices. These methods allow operation room personnel to preserve reproductive material for future use, providing greater flexibility in family planning. RB Atkinson and colleagues aimed to characterize demographics, costs, and workplace support for US surgeons using assisted reproductive technology (ART), adoption, and surrogacy to build their families. The study found that female surgeons were more likely to report delayed childbearing due to surgical training compared to male surgeons. Female surgeons were also older at their first pregnancy, with age over 35 associated with greater odds of ART use. The costs for ART, adoption, and surrogacy were substantial, with 60% of surgeons using adoption or surrogacy spending over $40,000. Most surgeons took minimal time off work for these treatments. The study highlighted the lack of strong workplace support for these family-building options in surgery, disproportionately impacting women and same-sex couples. The authors emphasized the need for equitable and inclusive environments that support all routes to parenthood, suggesting that such support is crucial for the recruitment and retention of a diverse surgical workforce. They recommended the implementation of policies and practices to normalize childbearing as part of an early surgical career, including financial support and equitable parental leave for surgeons pursuing ART, surrogacy, or adoption to become parents [28].

10. Workplace Policies and Support:

Workplaces can play a crucial role in supporting the reproductive health of operation room personnel. Implementing policies that promote work-life balance, offering fertility benefits, and providing resources for family planning can contribute to a supportive environment. This includes ensuring access to maternity and paternity leave, flexible work schedules, and comprehensive healthcare coverage. Even in not operation room personnel in the health care personnel pregnancy have lots of challenges in the scoping review on pregnancy in physicians, Marianne Casilla-Lennon and colleagues aimed to synthesize and assess evidence to understand the personal health and professional impact of physician pregnancy. The review, based on 407 manuscripts from 7 databases, revealed that physician pregnancy had notable effects on colleagues, leading to perceived increased workload and persistent stigmatization and discrimination. Despite work productivity and academic metrics being independent of pregnancy events, negative perceptions prevailed. Maternity leave policies were inconsistent and largely unsatisfactory. Women physicians faced occupational hazard risks and exhibited high rates of childbearing delay, abortion, and fertility treatment. Conflicting data were found regarding obstetric and fetal complication rates compared to controls. The study concluded that the impact of physician pregnancy on maternal and fetal health remains uncertain due to insufficient and poor-quality data. The findings highlighted the need for prospective risk-matched observational studies to better understand the implications of physician pregnancy [29]. also, Amalia J. Stefanou, unique considerations related to fertility and pregnancy for women surgeons are discussed. Women surgeons often face the decision to delay pregnancy and childbearing due to concerns about potential conflicts with work and training, especially among surgical trainees who encounter obstacles such as bias from peers and program directors, as well as work-life conflict. As a result, rates of infertility are higher in women surgeons compared to the general population, and assisted reproductive technologies are more frequently required. The article highlights that pregnancy during a surgical career introduces additional occupational hazards. Overall, the importance of awareness regarding these issues is emphasized to provide support for surgeons who decide to become parents while pursuing a surgical career [30].

11. Reproductive Health Education:

Operation room personnel should have access to comprehensive reproductive health education. This includes information about the potential reproductive risks associated with their profession, as well as guidance on family planning, fertility preservation, and reproductive health maintenance. Educational programs within healthcare institutions can empower individuals to make informed decisions about their reproductive well-being. In the study conducted by P.H. Rosenberg and H. Vänttinen, a mail questionnaire was sent to Finnish anaesthetists and paediatricians to assess the occupational hazards to reproduction and health. The incidence of diagnosed spontaneous miscarriages in anaesthetists' families was 10.2% of all pregnancies, while it was 13.2% in paediatricians' families. Smoking significantly increased the incidence of spontaneous miscarriages, with rates of 22.9% in smoking female anaesthetists and 17.2% in smoking female paediatricians. The gestation times for both full-term pregnancies and miscarriages were shorter in the anaesthetist group than in the paediatrician group. Congenital abnormalities appeared at an equal rate in both groups, but musculoskeletal abnormalities were notably higher in anaesthetists' children. Serious diseases occurred at low frequencies, with three cases of hepatic jaundice and three cases of viral myocarditis in anaesthetists indicating possible infectious hazards in anaesthetic work. Different infectious diseases of the respiratory and urinary tracts were more common among paediatricians. The study did not find evidence that gas pollution in operating rooms is harmful to personnel [31].

12. Regular Health Check-ups:

Regular health check-ups, including preconception health assessments, can help operation room personnel monitor their overall well-being. These check-ups may involve discussions about family planning, assessment of reproductive health, and addressing any specific concerns related to the occupational exposures associated with their roles [9, 32, 33] study by Erika L. Rangel delves into the intricate relationship between a surgical career and the reproductive experiences of female surgeons in the United States. With a focus on infertility and pregnancy complications, the survey-based research encompassed 850 surgeons, predominantly women. The findings revealed that female surgeons exhibited a pregnancy loss rate of 42%, more than double the general population's rate. Furthermore, they tended to have fewer children, often attributing delays in childbearing to the demands of surgical training. Assisted reproductive technology (ART) usage was notably higher among female surgeons (24.9%) compared to their male counterparts (17.1%). In addition to highlighting these challenges, the study drew attention to major pregnancy complications being more prevalent in female surgeons than in nonsurgeon partners, even after accounting for various factors. Notably, the risk of major complications increased for female surgeons working 12 or more hours per week during the last trimester. The study underscores the imperative need for a shift in the surgical culture to better support pregnancy and mitigate the risks associated with infertility and pregnancy complications in female surgeons [33]. nationwide survey in Canada explores the experiences and attitudes of residents and program directors in general surgery programs concerning pregnancy during residency. With a response rate of 30% from residents and 50% from program directors, the study identified significant issues, including the absence of specific maternity/parenting policies in general surgery programs. Residents reported hurdles such as inadequate policies, difficulties in breastfeeding, and increased workloads for their fellow resident colleagues. Strikingly, all program directors acknowledged the lack of a program-specific maternity/parenting policy. The study emphasizes the need for the development and implementation of comprehensive policies to address the challenges associated with pregnancy during general surgery residency [34].

The studies provided present a comprehensive exploration of the potential fertility and pregnancy-related challenges faced by operation room personnel, including surgeons, anesthesiologists, and other healthcare professionals. 

1. Exposure to Anesthetic Gases:

The studies by D.A. Bussard, C. Baeder and M. Albrecht, E.N. Cohen and colleagues, and JF Boivin collectively emphasize the potential reproductive risks associated with exposure to anesthetic gases. The research points to associations between anesthetic gases like nitrous oxide and halogenated agents with adverse outcomes such as spontaneous abortion and congenital anomalies. However, the evidence remains inconclusive, and further extensive studies are deemed essential for a comprehensive understanding. Notably, the meta-analysis by JF Boivin suggests an increased risk of spontaneous abortion associated with occupational exposure to anaesthetic gases. The variability in findings underscores the importance of considering study quality when evaluating these associations.

2. Radiation Exposure:

Studies, such as the one by Venita Chandra et al., shed light on the potential risks of radiation exposure for vascular surgeons. While maternal exposures were recorded, the fetal dosimeter readings were negligible, challenging the notion that fetal radiation exposure should deter women from pursuing careers in vascular surgery. The review by Matilda Anderson and Rose H. Goldman echoes the concern of increased rates of spontaneous abortion among female operating room personnel exposed to waste anesthetic gases during the first trimester of pregnancy. The need for comprehensive investigation into occupational and non-occupational factors impacting pregnancy outcomes is emphasized.

3. Chemical Exposure:

The review on occupational reproductive hazards for female surgeons by Matilda Anderson and Rose H. Goldman highlights the presence of reproductive hazards in the operating room, including exposure to chemicals, radiation, and surgical smoke. The study by J. F. Haas and D. Schottenfeld underlines the increased rates of spontaneous abortion, preterm delivery, growth restriction, and congenital abnormalities in female surgeons. These findings reinforce the importance of addressing specific hazards present in the operating room environment.

4. Shift Work and Circadian Rhythm Disruption:

The study by Rangel and colleagues provides insights into the incidence of infertility and pregnancy complications among female surgeons in the US, revealing elevated rates of pregnancy loss and major complications. The systematic review on the impact of shift work during pregnancy indicates associations with adverse outcomes, including preterm delivery and infants small for gestational age. Both studies underscore the heightened risk of adverse pregnancy outcomes for female operation room personnel engaged in irregular and overnight shifts.

5. Physical Strain and Ergonomics:

The study by M. Estryn-Béhar and colleagues associates the working conditions of operating room personnel with neuropsychological symptoms, tiredness, and a higher rate of spontaneous abortions. While not directly linked to fertility, these findings highlight the potential impact of physical strain on both mental and reproductive health.

6. Infections and Occupational Exposure:

The emphasis on infection control measures in the studies recognizes the occupational exposure to infectious agents faced by healthcare workers, including those in the operation room. Strict adherence to safety protocols and measures is crucial to mitigate these risks, protecting both personal health and potential pregnancy outcomes.

7. Mental Health and Stress Management:

The study by Natalia Dowgiałło-Gornowicz et al. explores the perceptions of patients and doctors regarding the professional activity of pregnant surgeons, highlighting concerns about reputational loss and financial stability. The broader discussion emphasizes the high-stress environment of the operation room and its potential implications for mental health, with chronic stress potentially impacting fertility.

8. Age-Related Considerations:

The reviews by Matilda Anderson and Rose H. Goldman, as well as AR Todd, TR Cawthorn, and C Temple-Oberle, draw attention to age-related considerations for female surgeons, linking delayed family planning due to career demands with age-related declines in fertility. The study by RB Atkinson and colleagues further emphasizes the impact of delayed childbearing on female surgeons, with associated costs and limited workplace support for family-building options.

9. Fertility Preservation Options:

The study by RB Atkinson and colleagues introduces the concept of fertility preservation options for operation room personnel, emphasizing the importance of proactive choices for individuals facing delayed family planning due to career advancement.

10. Workplace Policies and Support:

The scoping review by Marianne Casilla-Lennon and colleagues and the article by Amalia J. Stefanou highlight the need for supportive workplace policies for pregnant physicians and surgeons. The studies collectively underscore the importance of equitable and inclusive environments, formal maternity policies, and a shift in surgical culture to attract and retain a diverse workforce.

11. Reproductive Health Education:

The study by P.H. Rosenberg and H. Vänttinen emphasizes the importance of reproductive health education for anaesthetists and paediatricians, acknowledging the need for understanding occupational hazards to reproduction and health. In summary, while each study addresses specific facets of fertility and pregnancy considerations for operation room personnel, a comprehensive understanding necessitates a multidimensional approach. These studies collectively underscore the need for further research, comprehensive workplace interventions, and supportive policies to address the unique challenges faced by operation room personnel in maintaining reproductive health and achieving a balance between professional and personal life.

IRAN status

In exploring the spectrum of pregnancy complications among operating room personnel, it is essential to highlight the unique challenges faced by individuals in Iran within this occupational context. Iran, like many other countries, grapples with specific issues that contribute to the complexity of reproductive health among operating room personnel. Challenges include limited access to advanced reproductive health technologies, cultural stigmas surrounding infertility treatments, and potential disparities in workplace support structures. Additionally, societal expectations regarding gender roles may add an extra layer of complexity for female surgeons in balancing professional responsibilities with family planning. The cultural and societal context of Iran plays a crucial role in shaping the experiences of operating room personnel, necessitating a nuanced understanding of these challenges for the development of targeted interventions and policies. Addressing these specific challenges within the broader framework of reproductive health among operation room personnel is paramount for creating effective and culturally sensitive strategies to support the well-being of healthcare professionals in Iran. Moreover, the Iranian healthcare system faces systemic challenges that impact the reproductive health of operating room personnel. Issues such as limited resources, understaffing, and high patient loads can intensify the occupational hazards faced by healthcare professionals. The availability and implementation of safety measures, including exposure reduction protocols for anesthetic gases and radiation, may vary, contributing to disparities in the risks faced by personnel in different healthcare settings across Iran [35]. Furthermore, economic factors and financial barriers may hinder access to fertility preservation options and comprehensive reproductive health services. The cost associated with assisted reproductive technologies and family planning interventions may pose significant challenges for individuals working in the healthcare sector, potentially influencing their decisions regarding family planning and fertility treatments [36]. In addressing these challenges, it becomes crucial to advocate for policy changes and institutional support within the Iranian healthcare system. Promoting awareness and education about reproductive health, establishing clear workplace policies that address the unique needs of operating room personnel, and providing financial support for fertility treatments can contribute to mitigating these challenges. Collaboration between healthcare professionals, policymakers, and reproductive health experts is essential to develop strategies that address the specific socio-cultural and systemic factors influencing the reproductive health landscape in Iran [37]. As the article concludes its in-depth review, it emphasizes the importance of tailoring interventions to the unique challenges faced by operating room personnel in Iran. By acknowledging and addressing these challenges, the medical community can work towards fostering a more supportive and inclusive environment, ensuring the well-being of healthcare professionals pursuing both successful careers and fulfilling family lives in the context of the surgical field in Iran.

The collective body of research on fertility and pregnancy challenges faced by operation room personnel, including surgeons, anesthesiologists, and other healthcare professionals, underscores the complex interplay of occupational exposures, workplace conditions, and individual health factors. While acknowledging the diversity of these studies, a synthesis of findings reveals several key themes and implications. Firstly, exposure to anesthetic gases, radiation, chemicals, and other occupational hazards poses potential risks to reproductive health. The studies consistently highlight associations between certain occupational exposures and adverse pregnancy outcomes, including spontaneous abortion, congenital abnormalities, and growth restrictions. However, the evidence often remains inconclusive, necessitating further research to establish more definitive links and inform occupational safety guidelines.

Secondly, the demanding nature of the operation room environment, characterized by irregular shifts, physical strain, and high-stress levels, contributes to heightened risks for fertility and pregnancy complications. The studies emphasize the need for tailored workplace interventions, including ergonomic considerations, mental health support, and comprehensive infection control measures. Thirdly, age-related considerations and delayed family planning due to career demands emerge as significant factors impacting fertility among operation room personnel. The studies underscore the importance of proactive family planning options, fertility preservation, and supportive workplace policies to address the unique challenges faced by individuals pursuing surgical careers. Moreover, workplace policies and support structures play a pivotal role in shaping the reproductive experiences of operation room personnel. Inconsistent maternity leave policies, financial barriers to family-building options, and a lack of inclusivity contribute to the challenges faced by female surgeons in particular. The need for equitable and inclusive environments, formal maternity policies, and a shift in surgical culture is evident across multiple studies.

While the studies provide valuable insights into the multifaceted landscape of fertility and pregnancy challenges in the operation room, there is a clear call for a holistic and collaborative approach. Future research should focus on refining our understanding of specific occupational risks, establishing clearer causal relationships, and advocating for workplace policies that prioritize the reproductive health and well-being of operation room personnel. The findings underscore the importance of creating environments that not only safeguard the health of healthcare professionals but also enable them to navigate the complexities of family planning and parenthood while pursuing fulfilling careers in the surgical field.

Conflict of interest

None

Financial Disclosure

Authors received no financial support for the research, authorship, and/or publication of this article.

Author contributions

All authors participated in the design of the study and approved the final version of the manuscript.