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Performance of embryo transfer in fellowship training
REFLECTIONS Performance of embryo transfer in fellowship training Kresowick et al. (1) have provided data regarding fellowship training in embryo transfer (ET) that is reassuring, and at the same time, more than a bit disturbing. The authors analyzed nearly 10 years of ET data from the program at the University of Iowa. Their goal was to answer the question, ‘‘Does a fellow's 18 month protected research time adversely affect clinical performance, as specifically reflected in pregnancy rates after embryo transfer?’’ The study is well-designed, and the authors have presented a thoughtful discussion of potentially confounding factors, as well as relative gaps and weaknesses in the data. Their conclusions are well-supported within the limits of their analysis; we should all be reassured that the authors observed no significant decrement in the clinical pregnancy rates for the patients of 5 fellows after their 18-month research block, during which time they did no clinical work or ETs. They provide the similarly attractive suggestion that clinical outcomes for more experienced practitioners would likely not be adversely affected by time away or periods of reduced clinical activity. One would infer that once this technique is effectively mastered, time away will not erode successful outcomes. Based on their data set, the authors reported very important additional information, namely, that pregnancy rates after ETs performed by fellows do not seem to be different from those produced by faculty members (their Table 2) (1). A number of studies, some cited in their paper, catalog risk factors for poor outcomes after ET; key among them is physician experience. A threshold number of ETs, generally thought to be between 20 and 50, has been suggested to be the number needed before a practitioner becomes proficient in the technique (2, 3). The key question to ask from an educational point of view is, obviously, how fellows can be taught the technique of ET such that they can become expert by the end of their training. The authors referenced 1 study that showed that performing intrauterine inseminations (IUIs) did not affect the rate at which proficiency in ET was achieved (4). Regrettably, their discussion did not include suggestions for other strategies that might be more successful. Although several other educational approaches have been suggested (3, 5), we are nevertheless left with the ongoing conundrum of how best to ensure that fellows learn to do ET well. Perhaps the most disturbing observation is that our approach has apparently been to largely neglect the training of fellows in this technique. A survey of reproductive endocrinology and infertility (REI) fellows, as recently as 2012, reported that three fourths of the fellows were grossly undertrained in ET (<20 were performed), and two thirds of these trainees (almost half of all REI fellows) never performed an ET during their fellowship (4). Given the clear demonstration that at Iowa and at other programs fellows
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demonstrably become as proficient as faculty members in this technique, it is hard to understand how or why program leadership would continue to prohibit fellows from learning and performing this procedure. Having been in circumstances in which new faculty members had to be trained in ET by more-experienced current fellows, I can attest to the awkwardness of this inconsistency. To my knowledge, the motivation for prohibiting REI fellows from performing ETs has not been thoroughly studied. However, I strongly suspect that the reason is related to the fear that allowing them to do ETs would result in lower pregnancy rates, which would be reflected in clinic-specific national data reporting. An alternate explanation may be that practitioners think that patients who are expecting a faculty physician to perform their procedure should not be subjected to the potential risk of a poorer outcome associated with the ET being performed by a fellow. This rationale seems spurious, as it is clearly not invoked in a consistent manner for procedures for which outcomes are not reported. Fellows are certainly allowed to perform other techniques, such as IUIs, ultrasounds, hysterosalpingograms, and surgeries, under varying levels of supervision. The irony is that fellows who have little or no experience in ET obviously finish their program and become practicing physicians who are expected to perform all aspects of in vitro fertilization, including ETs. If patient outcomes do indeed suffer from physician inexperience, the overall impact is unchanged—it is simply shifted from the fellow to the new practitioner. I would submit that it is the responsibility of fellowship directors to prepare their fellows for all the important components of their future careers. I, again, find it ironic that fellows are required to devote substantial amounts of time to aspects of their curriculum that will be of little or no value after the fellowship, but three fourths of them are insufficiently trained in a technique that is clearly central to their future professional careers. Kresowick et al. (1) have demonstrated that we should have confidence that the technique of ET can be learned effectively during a fellowship, and that time away from clinical practice for other rotations or responsibilities does not adversely affect clinical outcomes. All REI fellowship and division directors should make it a priority to develop better educational and clinical strategies to teach fellows to become proficient in doing ETs without adversely affecting clinical outcomes. Ultimately, learning this technique in a well-organized and validated manner will benefit both fellows and patients, and it is just the right thing to do. William D. Schlaff, M.D. Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Jefferson Medical College, Philadelphia, Pennsylvania http://dx.doi.org/10.1016/j.fertnstert.2015.01.023 You can discuss this article with its authors and with other ASRM members at
631
REFLECTIONS http://fertstertforum.com/schlaffw-embryo-transferfellowship-training/ 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.
2.
3.
4.
REFERENCES 1.
632
Kresowick J, Sparks A, Duran EH, Shah DK. Lapse in embryo transfer training does not negatively affect clinical pregnancy rates
5.
for reproductive endocrinology and infertility fellows. Fertil Steril 2015; 103:728–33. Papageorgiou TC, Hearns-Stokes RM, Leondires MP, Miller BT, Chakraborty P, Cruess D, et al. Training of providers in embryo transfer: What is the minimum number of transfers required for proficiency? Hum Reprod 2001;16:1415–9. Lopez MJ, Garcia D, Rodriguez A, Colodron M, Vassena R, Vernaeve V. Individualized embryo transfer training: timing and performance. Hum Reprod 2014;29:1432–7. Shah DK, Missmer SA, Correia KF, Racowsky C, Ginsburg E. Efficacy of intrauterine inseminations as a training modality for performing embryo transfer in reproductive endocrinology and infertility fellowship programs. Fertil Steril 2013;100:386–91. Bishop L, Brezina PR, Segars J. Training in embryo transfer: How should it be done? Fertil Steril 2013;100:351–2.
VOL. 103 NO. 3 / MARCH 2015
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demonstrably become as proficient as faculty members in this technique, it is hard to understand how or why program leadership would continue to prohibit fellows from learning and performing this procedure. Having been in circumstances in which new faculty members had to be trained in ET by more-experienced current fellows, I can attest to the awkwardness of this inconsistency. To my knowledge, the motivation for prohibiting REI fellows from performing ETs has not been thoroughly studied. However, I strongly suspect that the reason is related to the fear that allowing them to do ETs would result in lower pregnancy rates, which would be reflected in clinic-specific national data reporting. An alternate explanation may be that practitioners think that patients who are expecting a faculty physician to perform their procedure should not be subjected to the potential risk of a poorer outcome associated with the ET being performed by a fellow. This rationale seems spurious, as it is clearly not invoked in a consistent manner for procedures for which outcomes are not reported. Fellows are certainly allowed to perform other techniques, such as IUIs, ultrasounds, hysterosalpingograms, and surgeries, under varying levels of supervision. The irony is that fellows who have little or no experience in ET obviously finish their program and become practicing physicians who are expected to perform all aspects of in vitro fertilization, including ETs. If patient outcomes do indeed suffer from physician inexperience, the overall impact is unchanged—it is simply shifted from the fellow to the new practitioner. I would submit that it is the responsibility of fellowship directors to prepare their fellows for all the important components of their future careers. I, again, find it ironic that fellows are required to devote substantial amounts of time to aspects of their curriculum that will be of little or no value after the fellowship, but three fourths of them are insufficiently trained in a technique that is clearly central to their future professional careers. Kresowick et al. (1) have demonstrated that we should have confidence that the technique of ET can be learned effectively during a fellowship, and that time away from clinical practice for other rotations or responsibilities does not adversely affect clinical outcomes. All REI fellowship and division directors should make it a priority to develop better educational and clinical strategies to teach fellows to become proficient in doing ETs without adversely affecting clinical outcomes. Ultimately, learning this technique in a well-organized and validated manner will benefit both fellows and patients, and it is just the right thing to do. William D. Schlaff, M.D. Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Jefferson Medical College, Philadelphia, Pennsylvania http://dx.doi.org/10.1016/j.fertnstert.2015.01.023 You can discuss this article with its authors and with other ASRM members at
631
REFLECTIONS http://fertstertforum.com/schlaffw-embryo-transferfellowship-training/ 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.
2.
3.
4.
REFERENCES 1.
632
Kresowick J, Sparks A, Duran EH, Shah DK. Lapse in embryo transfer training does not negatively affect clinical pregnancy rates
5.
for reproductive endocrinology and infertility fellows. Fertil Steril 2015; 103:728–33. Papageorgiou TC, Hearns-Stokes RM, Leondires MP, Miller BT, Chakraborty P, Cruess D, et al. Training of providers in embryo transfer: What is the minimum number of transfers required for proficiency? Hum Reprod 2001;16:1415–9. Lopez MJ, Garcia D, Rodriguez A, Colodron M, Vassena R, Vernaeve V. Individualized embryo transfer training: timing and performance. Hum Reprod 2014;29:1432–7. Shah DK, Missmer SA, Correia KF, Racowsky C, Ginsburg E. Efficacy of intrauterine inseminations as a training modality for performing embryo transfer in reproductive endocrinology and infertility fellowship programs. Fertil Steril 2013;100:386–91. Bishop L, Brezina PR, Segars J. Training in embryo transfer: How should it be done? Fertil Steril 2013;100:351–2.
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