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Are reproductive endocrinologists still gynecologists?
INKLINGS Are reproductive endocrinologists still gynecologists? When the subspecialty of reproductive endocrinology and infertility (REI) was formed within obstetrics and gynecology, the original focus was gynecologic and reproductive issues ranging from puberty through menopause. Expertise in the underpinning and orchestration of the menstrual cycles at the level of the hypothalamus, pituitary, ovary, and uterus allowed attention to both conception and contraception. Reproductive endocrinologists were consultants for complex gynecologic conditions such as management of fibroids, endometriosis, and abnormal bleeding, and REI was at the forefront of microsurgical techniques including tubal surgery and surgery to conserve the ovary. We were the first experts in noninvasive surgery. As successful techniques emerged to treat anovulation and tubal and male factor infertility, success rates increased, and more patients were referred to subspecialists.
Are reproductive endocrinologists still gynecologists? One of the first identity crises of our field was, as subspecialists, are we still obstetricians? Many early practitioners of REI treated women through their pregnancies and delivered the children they helped conceive. Soon it became clear that REI specialists were prudent to refer patients back to their obstetricians to maintain referrals and to concentrate on the growth of the field. Thus, we were no longer obstetricians. The advent of successful and streamlined ovulation induction and then in vitro fertilization (IVF) has further transformed our subspecialty. Now IVF is the ultimate tool to address almost all types of infertility. Use and success of IVF has dramatically increased, and we are entering a new age of preimplantation genetic diagnosis and screening. We are no longer specialists or consultants in menopause, family planning, adolescent medicine, or minimally invasive surgery. In fact, for the latter three areas, there is separate postgraduate fellowship training outside of REI. Perhaps we are no longer gynecologists? In 2014, the Society for Reproductive Endocrinology and Infertility (SREI) conducted a workforce and practice survey of practicing subspecialists in REI. The findings seem to confirm this evolution. The breakdown of current practice is: 63% infertility, 9% endocrinology, 10% reproductive surgery, and 8% research, with only 5% and 2% of time spent on gynecology and preventative health, respectively. On average, current REI practitioners conduct 12 major surgeries a year while personally conducting more than 140 egg retrievals. This practice pattern was also reflected when the survey queried our recollection of our training. When asked to assess how time spent during fellowship training prepared for current practice, respondents felt that our current training has ‘‘a surplus’’ of reproductive surgery and basic research, and not enough time devoted to male infertility, embryology, embryo transfer, and genetics. Is that gynecology? Perhaps telling are anecdotes overheard at meetings (and the subspecialty board examinations) that some in our subspecialty are referring patients with altered levels in thyroid 24
stimulation hormones or suspected glucose intolerance to medical endocrinologists for workup and stabilization before they are treated with IVF. Some refer women back to the general gynecologist for their Pap smears, breast examinations, and yearly pelvic examinations. Will we reach a day when the only gynecologic procedure in the repertoire of a REI practitioner is to perform an ultrasound to assess follicular growth? We also have a time in our career that we lament that training and practice has changed from the golden days. However, change in training and practice is not necessarily for the worse (except when IVF is treated like a commodity and volume is paramount to indication). As practice patterns change, it does question the scope of our training. Do we continue to train and grant board certification for topics we no longer practice, or do we change the training to reflect current practice trends? It is interesting that the bylaws of the SREI were amended only last year to include the ‘‘I.’’ When will we need to remove the ‘‘E’’ as we transform away from the practice of endocrinology?
If we are not gynecologists If we are not gynecologists, it is time for the mendacity and entropy to stop. Radical changes should be made in the training of the fellows and the practice of reproductive endocrinology and infertility. Let’s face it: we have moved from having an academic bent to a cooperate one. Training should be expanded so that fellows become skilled in running the embryology laboratory associated with their assisted reproductive technology (ART) program. The American Board of Bioanalysis has a program that provides certifications for Embryology Laboratory Directors (ELD). This should be an elective—not mandatory—part of the fellowship. In an editorial 1 year ago, Schlaff (1) suggested that REI specialists should also be responsible for managing male infertility. Should this include the surgical aspects? The rapid expansion and the scientific advances in preimplantation genetic diagnosis mean that genetics should be a more integral part of the program and that reproductive endocrinologist could also—if they elect to do so—become boarded in clinical genetics. Even though there is considerable overlap among the 25 areas for which reproductive endocrinologists are responsible (e.g., contraception, menopause, dysfunctional uterine bleeding, and gynecology), it is time to move ahead. Even polycystic ovary syndrome is moving out of our realm. The leader of this change has to be the American Board of Obstetrics and Gynecology (ABOG). Although change may take a long time to occur, one would predict that in the future those finishing their residency will be board certified in obstetrics and gynecology, but after that their maintenance of certification will only be in reproductive endocrinology and infertility (if that is their field of subspecialization). Today the ABOG states that less than 10% of an REI fellow’s time can be spent on gynecology. As A.A Milne’s Winnie-the-Pooh said, ‘‘I am not lost for I know where I am. But however, where I am may be lost.’’ Reproductive endocrinologists are not gynecologists in 21st VOL. 104 NO. 1 / JULY 2015
Fertility and Sterility® century America. Their areas of responsibility should be expanded, and the body of knowledge should be more and more about less and less. Kurt T. Barnhart, M.D., M.S.C.E.a Alan H. DeCherney, M.D.b a Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and b Reproductive Biology and Medicine Branch, Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
You can discuss this article with its authors and with other ASRM members at http://fertstertforum.com/barnhartk-reproductiveendocrinologists-gynecologists/ Use your smartphone to scan this QR code and connect to the discussion forum for this article now.* * Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace.
REFERENCE 1.
http://dx.doi.org/10.1016/j.fertnstert.2015.04.034
VOL. 104 NO. 1 / JULY 2015
Schlaff WD. Responding to change in reproductive endocrinology fellowships. Fertil Steril 2014;101:1510–1.
25
Are reproductive endocrinologists still gynecologists? One of the first identity crises of our field was, as subspecialists, are we still obstetricians? Many early practitioners of REI treated women through their pregnancies and delivered the children they helped conceive. Soon it became clear that REI specialists were prudent to refer patients back to their obstetricians to maintain referrals and to concentrate on the growth of the field. Thus, we were no longer obstetricians. The advent of successful and streamlined ovulation induction and then in vitro fertilization (IVF) has further transformed our subspecialty. Now IVF is the ultimate tool to address almost all types of infertility. Use and success of IVF has dramatically increased, and we are entering a new age of preimplantation genetic diagnosis and screening. We are no longer specialists or consultants in menopause, family planning, adolescent medicine, or minimally invasive surgery. In fact, for the latter three areas, there is separate postgraduate fellowship training outside of REI. Perhaps we are no longer gynecologists? In 2014, the Society for Reproductive Endocrinology and Infertility (SREI) conducted a workforce and practice survey of practicing subspecialists in REI. The findings seem to confirm this evolution. The breakdown of current practice is: 63% infertility, 9% endocrinology, 10% reproductive surgery, and 8% research, with only 5% and 2% of time spent on gynecology and preventative health, respectively. On average, current REI practitioners conduct 12 major surgeries a year while personally conducting more than 140 egg retrievals. This practice pattern was also reflected when the survey queried our recollection of our training. When asked to assess how time spent during fellowship training prepared for current practice, respondents felt that our current training has ‘‘a surplus’’ of reproductive surgery and basic research, and not enough time devoted to male infertility, embryology, embryo transfer, and genetics. Is that gynecology? Perhaps telling are anecdotes overheard at meetings (and the subspecialty board examinations) that some in our subspecialty are referring patients with altered levels in thyroid 24
stimulation hormones or suspected glucose intolerance to medical endocrinologists for workup and stabilization before they are treated with IVF. Some refer women back to the general gynecologist for their Pap smears, breast examinations, and yearly pelvic examinations. Will we reach a day when the only gynecologic procedure in the repertoire of a REI practitioner is to perform an ultrasound to assess follicular growth? We also have a time in our career that we lament that training and practice has changed from the golden days. However, change in training and practice is not necessarily for the worse (except when IVF is treated like a commodity and volume is paramount to indication). As practice patterns change, it does question the scope of our training. Do we continue to train and grant board certification for topics we no longer practice, or do we change the training to reflect current practice trends? It is interesting that the bylaws of the SREI were amended only last year to include the ‘‘I.’’ When will we need to remove the ‘‘E’’ as we transform away from the practice of endocrinology?
If we are not gynecologists If we are not gynecologists, it is time for the mendacity and entropy to stop. Radical changes should be made in the training of the fellows and the practice of reproductive endocrinology and infertility. Let’s face it: we have moved from having an academic bent to a cooperate one. Training should be expanded so that fellows become skilled in running the embryology laboratory associated with their assisted reproductive technology (ART) program. The American Board of Bioanalysis has a program that provides certifications for Embryology Laboratory Directors (ELD). This should be an elective—not mandatory—part of the fellowship. In an editorial 1 year ago, Schlaff (1) suggested that REI specialists should also be responsible for managing male infertility. Should this include the surgical aspects? The rapid expansion and the scientific advances in preimplantation genetic diagnosis mean that genetics should be a more integral part of the program and that reproductive endocrinologist could also—if they elect to do so—become boarded in clinical genetics. Even though there is considerable overlap among the 25 areas for which reproductive endocrinologists are responsible (e.g., contraception, menopause, dysfunctional uterine bleeding, and gynecology), it is time to move ahead. Even polycystic ovary syndrome is moving out of our realm. The leader of this change has to be the American Board of Obstetrics and Gynecology (ABOG). Although change may take a long time to occur, one would predict that in the future those finishing their residency will be board certified in obstetrics and gynecology, but after that their maintenance of certification will only be in reproductive endocrinology and infertility (if that is their field of subspecialization). Today the ABOG states that less than 10% of an REI fellow’s time can be spent on gynecology. As A.A Milne’s Winnie-the-Pooh said, ‘‘I am not lost for I know where I am. But however, where I am may be lost.’’ Reproductive endocrinologists are not gynecologists in 21st VOL. 104 NO. 1 / JULY 2015
Fertility and Sterility® century America. Their areas of responsibility should be expanded, and the body of knowledge should be more and more about less and less. Kurt T. Barnhart, M.D., M.S.C.E.a Alan H. DeCherney, M.D.b a Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and b Reproductive Biology and Medicine Branch, Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
You can discuss this article with its authors and with other ASRM members at http://fertstertforum.com/barnhartk-reproductiveendocrinologists-gynecologists/ Use your smartphone to scan this QR code and connect to the discussion forum for this article now.* * Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace.
REFERENCE 1.
http://dx.doi.org/10.1016/j.fertnstert.2015.04.034
VOL. 104 NO. 1 / JULY 2015
Schlaff WD. Responding to change in reproductive endocrinology fellowships. Fertil Steril 2014;101:1510–1.
25