- Email: [email protected]
UK urology trainees’ exposure to dedicated infertility training: How good is that training?
British Journal of Medical and Surgical Urology (2012) 5, 34—38
ORIGINAL ARTICLE
UK urology trainees’ exposure to dedicated infertility training: How good is that training? B.R. Grey a,b,∗, K.J. O’Flynn b,1, S.R. Payne a,2 a
Central Manchester University Hospitals NHS Foundation Trust, Department of Urology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK b Salford Royal NHS Foundation Trust, Department of Urology, Hope Hospital, Stott Lane, Salford M6 8HD, UK Received 30 July 2011 ; received in revised form 17 August 2011; accepted 20 August 2011
KEYWORDS Male; Infertility; Urology; Gynaecology; Training
Summary Objective: The management of male-factor infertility (MFI) is one component of the UK urological training curriculum. Sub-specialising gynaecologists, training in reproductive medicine, are also expected to achieve similar competencies. This study aimed to determine UK urology trainees’ views on the quality of their training in managing the infertile male. Methods: All UK urological trainees, identified through the British Association of Urological Surgeons (BAUS) or Joint Committee on Surgical Training (JCST) databases were e-mailed and invited to partake in an online survey, accessed through SurveyMonkeyTM . Results: 176 (51.6%) urological trainees responded. Only 3.6% were assured of exposure to training in MFI investigation and management and <35% had any exposure to vasectomy reversal. 61.3% wanted infertility to make up some part of their work as a consultant but only 27% rated their training as adequate. 79.9% felt threatened by the potential loss of skills and patients to gynaecologists with sub-specialist interests in reproductive medicine. Conclusions: UK urological trainees reported that exposure to dedicated training in MFI is suboptimal and ultimately, insufficient to equip them for the consultant practice they desire. Urology training needs re-structuring to ensure retention of this skill set and to support the aspirations of interested urological trainees. © 2011 British Association of Urological Surgeons. Published by Elsevier Ltd. All rights reserved.
∗ Corresponding author at: Salford Royal NHS Foundation Trust, Department of Urology, Hope Hospital, Stott Lane, Salford M6 8HD, UK. Tel.: +44 161 276 8529/206 5567; fax: +44 161 276 5814/206 5814. E-mail addresses: [email protected] (B.R. Grey), kieran.o’fl[email protected] (K.J. O’Flynn), [email protected] (S.R. Payne). 1 Tel.: +44 161 206 5567; fax: +44 161 206 5814. 2 Tel.: +44 161 276 8529; fax: +44 161 276 5814.
1875-9742/$ — see front matter © 2011 British Association of Urological Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjmsu.2011.08.005
UK urology trainees’ exposure to dedicated infertility training: How good is that training?
Introduction Since its introduction by the Specialist Advisory Committee (SAC) in urology and subsequent approval by the Postgraduate Medical Education Training Board (PMETB) in 2008, the Intercollegiate Surgical Curriculum Project (ISCP) has formalised the syllabus for urology training [1]. Trainees’ knowledge of this curriculum is tested by the Intercollegiate specialty examination in urology, in the form of the FRCS(Urol) examination. The management of primary and secondary male-factor infertility (MFI) are significant components of both the curriculum and subsequent examination constituting no less than 11 topic areas within the curriculum; two of these specifically require knowledge about the management of the infertile man following previous vasectomy. Feedback from previous candidates sitting the FRCS(Urol) examination shows that some trainees are uncomfortable with the management of the infertile couple [2] and it has been postulated that this may be a consequence of candidates’ insufficient knowledge of, and a lack of clinical exposure to, such aspects of the curriculum during a training programme’s placements. This prompted us to evaluate whether UK urology trainees felt that they received appropriate training in infertility to cover the ISCP requirements, meet the necessary knowledge standard to pass the FRCS(Urol) examination and ultimately, be sufficiently prepared for practice as a trained consultant urologist when gaining a certificate of completion of training (CCT). Male-factors are responsible for up to 25% of all cases of infertility and may contribute in a further 25% [3]. For some time there has been debate surrounding the most appropriate clinical specialty to assess and manage couples in whom a malefactor has been identified as a contributing cause. Nicopoullos et al. argued that the diagnosis and management of the azoospermic male should be led by urologists with appropriate support from a fertility unit but that those ‘non-azoospermic’ males should be investigated and managed by a multidisciplinary team consisting of urologists, gynaecologists and embryologists in a dedicated assisted reproduction unit [4]. Unlike uro-oncology [5,6] the impact of specialist, as compared to non-specialist care, has not yet been evaluated in the management of infertility-related problems despite moves towards sub-specialist management of this problem. Currently, the SAC in urology recommends four
35
post-CCT fellowships for further andrology training within the UK although the degree of exposure to infertility within these programmes is poorly defined with the majority of emphasis being on penile andrology. The Royal College of Obstetricians and Gynaecologists (RCOG), by comparison, have published the competencies required of trainees wishing to sub-specialise in reproductive medicine. These include the ability to independently perform percutaneous epididymal sperm aspiration (PESA), microscopic epididymal sperm aspiration (MESA), testicular sperm aspiration (TESA) and open testicular biopsy (Open TeSE) [7]. In addition, reproductive medicine trainees are required to have at least observed vasectomy, reversal of vasectomy and varicocele ligation but are not expected to be able to perform these or carry them out independently at the completion of their training. This variation in training requirements between the two specialties raises the question of who is better trained to perform the panoply of procedures required in managing the infertile male and whether there is a desire from the urological community to retain the investigation and surgical management of the infertile male in its remit.
Aims The aims of this study were as follows: (1) To determine whether UK Urology trainees felt they have adequate knowledge for the assessment and management of men with infertility so as to meet the requirements of the FRCS(Urol) examination and vocational experience, sufficient to practice as a consultant urologist seeing infertile men, following CCT. (2) To determine trainees’ exposure to the procedure of vasectomy reversal, using this as a surrogate for global surgical expertise in the management of the man with obstructive azoospermia. (3) To determine whether urological trainees had a desire to include the assessment and management of MFI in their future consultant practice. (4) To see if urological trainees perceived the sub-specialisation of reproductive medicine in gynaecology, and the inclusion of some male surgical competencies in their syllabus, as a threat to their future consultant practice and to determine who would be best in managing couples with infertility where there was a male-factor.
36
Methods All UK urological trainees registered with the JCST or identified as a junior member of BAUS, were sent a weblink to a SurveyMonkeyTM questionnaire, via email. After 6 weeks, an e-reminder was sent. Initial questions determined the demographics of the trainee group regarding year of training and their geographic deanery distribution. As a general determinant of the trainees’ interest in an andrological practice, we asked how many trainees were members of the BAUS section of Andrology. The second part of the survey aimed to determine trainees’ level of exposure to the management of an infertile male and asked their views on whether they felt this experience would be sufficient to meet the requirements of the ISCP curriculum and whether it would influence their choice of sub-specialisation as a consultant urologist. The third part of the survey asked details of their experience of vasectomy reversal so as to provide an objective assessment of their exposure to surgery for MFI, one of a number of skills which might define appropriate training for any specialist wishing to have an infertility practice. The fourth part of the survey asked whether urological trainees saw infertility becoming part of their consultant practice and the fifth aspect asked them whether they thought that reproductive medicine trainees in gynaecology were appropriately trained for surgery in the male and whether they were seen as a potential threat to their practice as a consultant urologist.
Results After two requests to complete the survey, 176 (51.6%) of UK urological trainees had responded. All grades of trainee were represented but the majority were at the StR4/SpR2 level (23.2%). One respondent (0.7%) was undertaking a postCCT fellowship in andrology. Trainees from all the UK postgraduate deaneries responded though 17% wished to keep their affiliation anonymous. Approximately one quarter of respondents (22.7%) were members of the BAUS section of andrology and a further 10% intended to become one. Only 3.6% were assured of exposure to training in infertility management, though 49.6% could potentially receive such expertise if they rotated through a particular unit during their training programme. However, such a rotation was not guaranteed. Although, 0.7% of trainees believed there was an inter-regional agreement in place
B.R. Grey et al. to arrange training elsewhere in the UK, unfortunately, 33.6% had no access to an infertility service as a learning opportunity at all and 12.4% had no such service available in their region. Of those trainees that had access to training opportunities, 81% gained experience in MFI only, whereas the remainder had opportunity to learn about the investigation and management relevant to both partners. Despite only 3.6% of trainees being guaranteed dedicated clinical experience in infertility management, 27.0% of trainees felt they would have ultimately received sufficient training by the end of their rotation to satisfy the requirements of the ISCP curriculum, FRCS(Urol) and subsequent clinical practice as a consultant urologist. A further 39.5% were unsure if they would meet the standard set by ISCP and one third (33.6%) were prepared to say they did not feel they would be sufficiently competent. Of these individuals, 71.4% planned to make up for this deficiency by personal study, 19.0% intended to undertake a training course and 9.6% planned a clinical attachment outside of their training programme. With regard to trainees’ experience of vasectomy reversal, 23.3% felt adequately informed to be able to counsel a couple regarding vasectomy reversal, and alternatives to it, but the majority were either not confident about (66.0%) or unsure of (10.7%) their abilities. Only 1.3% of trainees had seen, assisted with, or performed more than 10 vasectomy reversals. A large number of respondents (49.0%) had never even seen the procedure being performed. Only 8.0% of all trainees planned to perform the procedure as part of their future consultant practice. For those that had actually performed the procedure as a trainee, this figure increased to 13.2%. Although 16.4% of respondents were unsure as to their plans for consultant practice, 22.4% were clear they did not want infertility management to feature in any part of their future career. Approximately a further half wished to provide some MFI service within a general urological practice in the NHS, (25.0%), privately (2.0%), or both together (24.3%). Least commonly, trainees declared an interest in providing an infertility service as part of their practice as an andrology specialist. Only 3.9% wanted the specialist investigation and management of sub-fertility to form part of their NHS practice, 1.3% their private practice and 4.6% both. When advised of the male surgical competencies required of gynaecology trainees with a sub-specialist interest in reproductive medicine, 87.5% of urological trainees felt acquisition of such skills was inappropriate and 73.5% saw
UK urology trainees’ exposure to dedicated infertility training: How good is that training? the move as a threat to their training and future practice as a consultant. Ultimately, 79.9% felt gynaecological sub-specialists in reproductive medicine posed a potential loss to a urological skill base.
Discussion Traditionally, MFI has been treated by urologists with appropriate gynaecological and embryological input, to optimise outcomes for patients and allow couples access to the most appropriate treatment modalities. This has often been provided as part of a general urological service, with increasing provision within specialist clinics provided purely urologically, gynaecologically, or as part of a collaborative joint clinic. In the current financial climate, the NHS is under increasing pressure to provide a safe, effective and cost-efficient service [8] and the scope for commissioning expensive joint working is becoming a less attractive option to the purchasers of this aspect of healthcare. It has been shown that an andrological assessment and treatment may often be feasible prior to resorting to expensive assisted reproductive techniques (ART) [9]. This emphasises the need for as accurate a diagnosis of the cause of MFI as possible and more targeted therapy rather than resorting to empirical ART [10]. There is concern that despite sub-specialist training being available towards the latter part of their training, gynaecologists do not have the same degree of anatomical, pathological, or surgical experience of the male genital tract, nor are they as used, as urologists, to examining it for subtle abnormal findings [11]. The German Society of Andrology has developed a highly specialised programme for urological trainees to ring-fence MFI as a sub-specialist area within urology [12], something that, in the UK, would be best provided in post-CCT fellowships similar to those for other subspecialist areas [13]. Whilst sub-specialisation, in the investigation and management of infertility, is likely to reap the best results for patients, appropriate training still needs to be provided for the initial management of the infertile man by core urologists. This study has shown that surprisingly few urology trainees are guaranteed a rotation through a post with exposure to core training in infertility with many having no access to a clinical learning opportunity within their training deanery and even fewer an exposure to the surgical management of the infertile male. Ultimately, only 27.0% of respondents felt their training
37
would be sufficient to practise as a consultant urologist, and this suggests that there is insufficient exposure to infertility training for trainee urologists, which may explain their views after sitting the FRCS(Urol) examination [2]. With rationalisation of specialist services and creation of more tertiary referral centres, it is less likely that urological training is going to include experience in an infertility service. Whilst it is accepted that not all urological trainees need to have in-depth knowledge of MFI, sufficient knowledge to cover the curriculum, ought to be available to all. In particular, specific knowledge about the management of the couple presenting with azoospermia should be a core expectation. BAUS already runs a training course dedicated to infertility management and knowledge is often acquired within regional teaching programmes. Such didactic teaching does not, however, frequently compliment the vocational experience afforded at the clinical interface. Virtual learning environments (VLEs) might help provide some of these vocational skills and facilitate the learning of surgical techniques necessary for surgical sperm retrieval, if they are not available locally. However, VLEs are unlikely to replicate the advanced communications skills demanded in counselling couples where obstructive azoospermia is the cause of their inability to procreate. Traditional, urologically based, male genital surgical procedures have become an increasing part of the management of men with both primary obstructive and non-obstructive azoospermia and secondary azoospermia following previous vasectomy. The RCOG have included techniques for surgical retrieval of sperm as part of their subspecialist training in reproductive medicine without specifying the arbiters of competence and excluding reconstructive surgery from their trainee’s remit. Knowledge about the techniques of surgical sperm retrieval and reconstructive surgery should be a core expectation of all urological trainees and the ability to perform these within the remit of appropriately trained sub-specialists interfacing with an andrology laboratory. There is no doubt that any appropriately trained urologist, or specialist in reproductive medicine, is capable of having the knowledge base to counsel a couple presenting with infertility complicated by male factors. However, we believe that the breadth of exposure of urological trainees to the clinical examination of the male genital tract, interpretation of imaging and investigative data relevant to testicular function and, in particular, the operative skills in the genital area make urologists a more logical choice
38
B.R. Grey et al.
for managing couples where there is infertility due to an absence of sperm from the ejaculate. This applies to secondary azoospermia when all vaso-epididymal reconstructive surgery requires the use of magnification, currently not included in the syllabus for sub-specialist gynaecological trainees. Whilst the response rate to this survey was 52%, we are confident that it, at least, gives a reasonable snap shot of the training opportunities available nationally. It appears that the majority of UK urological trainees want infertility management to feature in some part of their future practice in general urology or sub-specialist andrology. As UK urological trainees do have a desire to be trained in the management of MFI they are right to feel threatened by the potential loss of such a skill base to gynaecological colleagues. This survey suggests that a significant review of the current opportunities for training in MFI, for urological trainees, should be undertaken.
Conclusions The majority of urological trainees in the UK report that exposure to dedicated training in MFI is insufficient for their expected needs at CCT. Urological training needs re-structuring to ensure that core skills acquisition, appropriate to the management of MFI, in particular due to azoospermia, are available to all trainee urological surgeons.
Nomenclature MFI BAUS JCST SAC PMETB
male-factor infertility British Association of Urological Surgeons Joint Committee on Surgical Training Specialist Advisory Committee Postgraduate Medical Education Training Board ISCP Intercollegiate Surgical Curriculum Project CCT certificate of completion of training RCOG Royal College of Obstetricians and Gynaecologists PESA percutaneous epididymal sperm aspiration MESA microscopic epididymal sperm aspiration TESA testicular sperm aspiration Open TeSE open testicular biopsy
ART VLE
assisted reproductive techniques virtual learning environment
Conflict of interest None declared.
Sources of funding None.
References [1] Eardley I, George N, O’Flynn KJ. The curriculum for urological training (years 1—7 (ST1—ST7)). SAC in Urology; 2008. [2] Payne SR, Pickard RS, O’Flynn KJ, Winton EP. Does the Intercollegiate Specialty Examination in urology (FRCS Urol) assess the breadth of the urology syllabus? British Journal of Medical and Surgical Urology 2011;4:139—47. [3] Templeton A, Ashok P, Bhattacharya S, Gazvani R, Hamilton M, Hamoda H, et al. Male-factor infertility. In: Management of infertility for the MRCOG and beyond. London, UK: RCOG Press; 2000. p. 23—46. [4] Nicopoullos JDM, Gilling-Smith C, Ramsay JWA. Male-factor infertility: do we really need urologists? A gynaecological view. BJU Int 2004;93:1188—90. [5] National Institute of Clinical Excellence (NICE). Improving outcomes in urological cancer; 2002 [accessed 12.6.11] http://www.nice.org.uk. [6] National Institute of Clinical Excellence (NICE). Fertility: assessment and treatment for people with fertility problems (guideline CG11); 2004 [accessed 12.6.11] http://www.nice.org.uk. [7] Royal College of Obstetricians and Gynaecologists. Reproductive medicine curriculum and required competences; 2011 [accessed 14.6.11] http://www.rcog.org.uk. [8] Hamilton M. Developing clinical standards and accrediting clinics in infertility care. Hum Fertil (Camb) 2003;6(Suppl. 1):S30—2. [9] Pierik FH, Van Ginneken AM, Dohle GR, Vreeburg JT, Weber RF. The advantages of standardized evaluation of male infertility. Int J Androl 2000;23:340—6. [10] Jequier AM. The importance of diagnosis in the clinical management of infertility in the male. Reprod Biomed Online 2006;13:331—5. [11] Jequier AM. Clinical andrology — still a major problem in the treatment of infertility. Hum Reprod 2004;19:1245—9. [12] Kliesch S. Continuing medical education in andrology: continuing education between wish and reality. Urologe A 2010;49:930—3. [13] Andrich DE, Mundy AR. A Fellowship programme in reconstructive urological surgery: what is it and what is it for? BJU Int 2010;106:108—11.
Available online at www.sciencedirect.com
ORIGINAL ARTICLE
UK urology trainees’ exposure to dedicated infertility training: How good is that training? B.R. Grey a,b,∗, K.J. O’Flynn b,1, S.R. Payne a,2 a
Central Manchester University Hospitals NHS Foundation Trust, Department of Urology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK b Salford Royal NHS Foundation Trust, Department of Urology, Hope Hospital, Stott Lane, Salford M6 8HD, UK Received 30 July 2011 ; received in revised form 17 August 2011; accepted 20 August 2011
KEYWORDS Male; Infertility; Urology; Gynaecology; Training
Summary Objective: The management of male-factor infertility (MFI) is one component of the UK urological training curriculum. Sub-specialising gynaecologists, training in reproductive medicine, are also expected to achieve similar competencies. This study aimed to determine UK urology trainees’ views on the quality of their training in managing the infertile male. Methods: All UK urological trainees, identified through the British Association of Urological Surgeons (BAUS) or Joint Committee on Surgical Training (JCST) databases were e-mailed and invited to partake in an online survey, accessed through SurveyMonkeyTM . Results: 176 (51.6%) urological trainees responded. Only 3.6% were assured of exposure to training in MFI investigation and management and <35% had any exposure to vasectomy reversal. 61.3% wanted infertility to make up some part of their work as a consultant but only 27% rated their training as adequate. 79.9% felt threatened by the potential loss of skills and patients to gynaecologists with sub-specialist interests in reproductive medicine. Conclusions: UK urological trainees reported that exposure to dedicated training in MFI is suboptimal and ultimately, insufficient to equip them for the consultant practice they desire. Urology training needs re-structuring to ensure retention of this skill set and to support the aspirations of interested urological trainees. © 2011 British Association of Urological Surgeons. Published by Elsevier Ltd. All rights reserved.
∗ Corresponding author at: Salford Royal NHS Foundation Trust, Department of Urology, Hope Hospital, Stott Lane, Salford M6 8HD, UK. Tel.: +44 161 276 8529/206 5567; fax: +44 161 276 5814/206 5814. E-mail addresses: [email protected] (B.R. Grey), kieran.o’fl[email protected] (K.J. O’Flynn), [email protected] (S.R. Payne). 1 Tel.: +44 161 206 5567; fax: +44 161 206 5814. 2 Tel.: +44 161 276 8529; fax: +44 161 276 5814.
1875-9742/$ — see front matter © 2011 British Association of Urological Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjmsu.2011.08.005
UK urology trainees’ exposure to dedicated infertility training: How good is that training?
Introduction Since its introduction by the Specialist Advisory Committee (SAC) in urology and subsequent approval by the Postgraduate Medical Education Training Board (PMETB) in 2008, the Intercollegiate Surgical Curriculum Project (ISCP) has formalised the syllabus for urology training [1]. Trainees’ knowledge of this curriculum is tested by the Intercollegiate specialty examination in urology, in the form of the FRCS(Urol) examination. The management of primary and secondary male-factor infertility (MFI) are significant components of both the curriculum and subsequent examination constituting no less than 11 topic areas within the curriculum; two of these specifically require knowledge about the management of the infertile man following previous vasectomy. Feedback from previous candidates sitting the FRCS(Urol) examination shows that some trainees are uncomfortable with the management of the infertile couple [2] and it has been postulated that this may be a consequence of candidates’ insufficient knowledge of, and a lack of clinical exposure to, such aspects of the curriculum during a training programme’s placements. This prompted us to evaluate whether UK urology trainees felt that they received appropriate training in infertility to cover the ISCP requirements, meet the necessary knowledge standard to pass the FRCS(Urol) examination and ultimately, be sufficiently prepared for practice as a trained consultant urologist when gaining a certificate of completion of training (CCT). Male-factors are responsible for up to 25% of all cases of infertility and may contribute in a further 25% [3]. For some time there has been debate surrounding the most appropriate clinical specialty to assess and manage couples in whom a malefactor has been identified as a contributing cause. Nicopoullos et al. argued that the diagnosis and management of the azoospermic male should be led by urologists with appropriate support from a fertility unit but that those ‘non-azoospermic’ males should be investigated and managed by a multidisciplinary team consisting of urologists, gynaecologists and embryologists in a dedicated assisted reproduction unit [4]. Unlike uro-oncology [5,6] the impact of specialist, as compared to non-specialist care, has not yet been evaluated in the management of infertility-related problems despite moves towards sub-specialist management of this problem. Currently, the SAC in urology recommends four
35
post-CCT fellowships for further andrology training within the UK although the degree of exposure to infertility within these programmes is poorly defined with the majority of emphasis being on penile andrology. The Royal College of Obstetricians and Gynaecologists (RCOG), by comparison, have published the competencies required of trainees wishing to sub-specialise in reproductive medicine. These include the ability to independently perform percutaneous epididymal sperm aspiration (PESA), microscopic epididymal sperm aspiration (MESA), testicular sperm aspiration (TESA) and open testicular biopsy (Open TeSE) [7]. In addition, reproductive medicine trainees are required to have at least observed vasectomy, reversal of vasectomy and varicocele ligation but are not expected to be able to perform these or carry them out independently at the completion of their training. This variation in training requirements between the two specialties raises the question of who is better trained to perform the panoply of procedures required in managing the infertile male and whether there is a desire from the urological community to retain the investigation and surgical management of the infertile male in its remit.
Aims The aims of this study were as follows: (1) To determine whether UK Urology trainees felt they have adequate knowledge for the assessment and management of men with infertility so as to meet the requirements of the FRCS(Urol) examination and vocational experience, sufficient to practice as a consultant urologist seeing infertile men, following CCT. (2) To determine trainees’ exposure to the procedure of vasectomy reversal, using this as a surrogate for global surgical expertise in the management of the man with obstructive azoospermia. (3) To determine whether urological trainees had a desire to include the assessment and management of MFI in their future consultant practice. (4) To see if urological trainees perceived the sub-specialisation of reproductive medicine in gynaecology, and the inclusion of some male surgical competencies in their syllabus, as a threat to their future consultant practice and to determine who would be best in managing couples with infertility where there was a male-factor.
36
Methods All UK urological trainees registered with the JCST or identified as a junior member of BAUS, were sent a weblink to a SurveyMonkeyTM questionnaire, via email. After 6 weeks, an e-reminder was sent. Initial questions determined the demographics of the trainee group regarding year of training and their geographic deanery distribution. As a general determinant of the trainees’ interest in an andrological practice, we asked how many trainees were members of the BAUS section of Andrology. The second part of the survey aimed to determine trainees’ level of exposure to the management of an infertile male and asked their views on whether they felt this experience would be sufficient to meet the requirements of the ISCP curriculum and whether it would influence their choice of sub-specialisation as a consultant urologist. The third part of the survey asked details of their experience of vasectomy reversal so as to provide an objective assessment of their exposure to surgery for MFI, one of a number of skills which might define appropriate training for any specialist wishing to have an infertility practice. The fourth part of the survey asked whether urological trainees saw infertility becoming part of their consultant practice and the fifth aspect asked them whether they thought that reproductive medicine trainees in gynaecology were appropriately trained for surgery in the male and whether they were seen as a potential threat to their practice as a consultant urologist.
Results After two requests to complete the survey, 176 (51.6%) of UK urological trainees had responded. All grades of trainee were represented but the majority were at the StR4/SpR2 level (23.2%). One respondent (0.7%) was undertaking a postCCT fellowship in andrology. Trainees from all the UK postgraduate deaneries responded though 17% wished to keep their affiliation anonymous. Approximately one quarter of respondents (22.7%) were members of the BAUS section of andrology and a further 10% intended to become one. Only 3.6% were assured of exposure to training in infertility management, though 49.6% could potentially receive such expertise if they rotated through a particular unit during their training programme. However, such a rotation was not guaranteed. Although, 0.7% of trainees believed there was an inter-regional agreement in place
B.R. Grey et al. to arrange training elsewhere in the UK, unfortunately, 33.6% had no access to an infertility service as a learning opportunity at all and 12.4% had no such service available in their region. Of those trainees that had access to training opportunities, 81% gained experience in MFI only, whereas the remainder had opportunity to learn about the investigation and management relevant to both partners. Despite only 3.6% of trainees being guaranteed dedicated clinical experience in infertility management, 27.0% of trainees felt they would have ultimately received sufficient training by the end of their rotation to satisfy the requirements of the ISCP curriculum, FRCS(Urol) and subsequent clinical practice as a consultant urologist. A further 39.5% were unsure if they would meet the standard set by ISCP and one third (33.6%) were prepared to say they did not feel they would be sufficiently competent. Of these individuals, 71.4% planned to make up for this deficiency by personal study, 19.0% intended to undertake a training course and 9.6% planned a clinical attachment outside of their training programme. With regard to trainees’ experience of vasectomy reversal, 23.3% felt adequately informed to be able to counsel a couple regarding vasectomy reversal, and alternatives to it, but the majority were either not confident about (66.0%) or unsure of (10.7%) their abilities. Only 1.3% of trainees had seen, assisted with, or performed more than 10 vasectomy reversals. A large number of respondents (49.0%) had never even seen the procedure being performed. Only 8.0% of all trainees planned to perform the procedure as part of their future consultant practice. For those that had actually performed the procedure as a trainee, this figure increased to 13.2%. Although 16.4% of respondents were unsure as to their plans for consultant practice, 22.4% were clear they did not want infertility management to feature in any part of their future career. Approximately a further half wished to provide some MFI service within a general urological practice in the NHS, (25.0%), privately (2.0%), or both together (24.3%). Least commonly, trainees declared an interest in providing an infertility service as part of their practice as an andrology specialist. Only 3.9% wanted the specialist investigation and management of sub-fertility to form part of their NHS practice, 1.3% their private practice and 4.6% both. When advised of the male surgical competencies required of gynaecology trainees with a sub-specialist interest in reproductive medicine, 87.5% of urological trainees felt acquisition of such skills was inappropriate and 73.5% saw
UK urology trainees’ exposure to dedicated infertility training: How good is that training? the move as a threat to their training and future practice as a consultant. Ultimately, 79.9% felt gynaecological sub-specialists in reproductive medicine posed a potential loss to a urological skill base.
Discussion Traditionally, MFI has been treated by urologists with appropriate gynaecological and embryological input, to optimise outcomes for patients and allow couples access to the most appropriate treatment modalities. This has often been provided as part of a general urological service, with increasing provision within specialist clinics provided purely urologically, gynaecologically, or as part of a collaborative joint clinic. In the current financial climate, the NHS is under increasing pressure to provide a safe, effective and cost-efficient service [8] and the scope for commissioning expensive joint working is becoming a less attractive option to the purchasers of this aspect of healthcare. It has been shown that an andrological assessment and treatment may often be feasible prior to resorting to expensive assisted reproductive techniques (ART) [9]. This emphasises the need for as accurate a diagnosis of the cause of MFI as possible and more targeted therapy rather than resorting to empirical ART [10]. There is concern that despite sub-specialist training being available towards the latter part of their training, gynaecologists do not have the same degree of anatomical, pathological, or surgical experience of the male genital tract, nor are they as used, as urologists, to examining it for subtle abnormal findings [11]. The German Society of Andrology has developed a highly specialised programme for urological trainees to ring-fence MFI as a sub-specialist area within urology [12], something that, in the UK, would be best provided in post-CCT fellowships similar to those for other subspecialist areas [13]. Whilst sub-specialisation, in the investigation and management of infertility, is likely to reap the best results for patients, appropriate training still needs to be provided for the initial management of the infertile man by core urologists. This study has shown that surprisingly few urology trainees are guaranteed a rotation through a post with exposure to core training in infertility with many having no access to a clinical learning opportunity within their training deanery and even fewer an exposure to the surgical management of the infertile male. Ultimately, only 27.0% of respondents felt their training
37
would be sufficient to practise as a consultant urologist, and this suggests that there is insufficient exposure to infertility training for trainee urologists, which may explain their views after sitting the FRCS(Urol) examination [2]. With rationalisation of specialist services and creation of more tertiary referral centres, it is less likely that urological training is going to include experience in an infertility service. Whilst it is accepted that not all urological trainees need to have in-depth knowledge of MFI, sufficient knowledge to cover the curriculum, ought to be available to all. In particular, specific knowledge about the management of the couple presenting with azoospermia should be a core expectation. BAUS already runs a training course dedicated to infertility management and knowledge is often acquired within regional teaching programmes. Such didactic teaching does not, however, frequently compliment the vocational experience afforded at the clinical interface. Virtual learning environments (VLEs) might help provide some of these vocational skills and facilitate the learning of surgical techniques necessary for surgical sperm retrieval, if they are not available locally. However, VLEs are unlikely to replicate the advanced communications skills demanded in counselling couples where obstructive azoospermia is the cause of their inability to procreate. Traditional, urologically based, male genital surgical procedures have become an increasing part of the management of men with both primary obstructive and non-obstructive azoospermia and secondary azoospermia following previous vasectomy. The RCOG have included techniques for surgical retrieval of sperm as part of their subspecialist training in reproductive medicine without specifying the arbiters of competence and excluding reconstructive surgery from their trainee’s remit. Knowledge about the techniques of surgical sperm retrieval and reconstructive surgery should be a core expectation of all urological trainees and the ability to perform these within the remit of appropriately trained sub-specialists interfacing with an andrology laboratory. There is no doubt that any appropriately trained urologist, or specialist in reproductive medicine, is capable of having the knowledge base to counsel a couple presenting with infertility complicated by male factors. However, we believe that the breadth of exposure of urological trainees to the clinical examination of the male genital tract, interpretation of imaging and investigative data relevant to testicular function and, in particular, the operative skills in the genital area make urologists a more logical choice
38
B.R. Grey et al.
for managing couples where there is infertility due to an absence of sperm from the ejaculate. This applies to secondary azoospermia when all vaso-epididymal reconstructive surgery requires the use of magnification, currently not included in the syllabus for sub-specialist gynaecological trainees. Whilst the response rate to this survey was 52%, we are confident that it, at least, gives a reasonable snap shot of the training opportunities available nationally. It appears that the majority of UK urological trainees want infertility management to feature in some part of their future practice in general urology or sub-specialist andrology. As UK urological trainees do have a desire to be trained in the management of MFI they are right to feel threatened by the potential loss of such a skill base to gynaecological colleagues. This survey suggests that a significant review of the current opportunities for training in MFI, for urological trainees, should be undertaken.
Conclusions The majority of urological trainees in the UK report that exposure to dedicated training in MFI is insufficient for their expected needs at CCT. Urological training needs re-structuring to ensure that core skills acquisition, appropriate to the management of MFI, in particular due to azoospermia, are available to all trainee urological surgeons.
Nomenclature MFI BAUS JCST SAC PMETB
male-factor infertility British Association of Urological Surgeons Joint Committee on Surgical Training Specialist Advisory Committee Postgraduate Medical Education Training Board ISCP Intercollegiate Surgical Curriculum Project CCT certificate of completion of training RCOG Royal College of Obstetricians and Gynaecologists PESA percutaneous epididymal sperm aspiration MESA microscopic epididymal sperm aspiration TESA testicular sperm aspiration Open TeSE open testicular biopsy
ART VLE
assisted reproductive techniques virtual learning environment
Conflict of interest None declared.
Sources of funding None.
References [1] Eardley I, George N, O’Flynn KJ. The curriculum for urological training (years 1—7 (ST1—ST7)). SAC in Urology; 2008. [2] Payne SR, Pickard RS, O’Flynn KJ, Winton EP. Does the Intercollegiate Specialty Examination in urology (FRCS Urol) assess the breadth of the urology syllabus? British Journal of Medical and Surgical Urology 2011;4:139—47. [3] Templeton A, Ashok P, Bhattacharya S, Gazvani R, Hamilton M, Hamoda H, et al. Male-factor infertility. In: Management of infertility for the MRCOG and beyond. London, UK: RCOG Press; 2000. p. 23—46. [4] Nicopoullos JDM, Gilling-Smith C, Ramsay JWA. Male-factor infertility: do we really need urologists? A gynaecological view. BJU Int 2004;93:1188—90. [5] National Institute of Clinical Excellence (NICE). Improving outcomes in urological cancer; 2002 [accessed 12.6.11] http://www.nice.org.uk. [6] National Institute of Clinical Excellence (NICE). Fertility: assessment and treatment for people with fertility problems (guideline CG11); 2004 [accessed 12.6.11] http://www.nice.org.uk. [7] Royal College of Obstetricians and Gynaecologists. Reproductive medicine curriculum and required competences; 2011 [accessed 14.6.11] http://www.rcog.org.uk. [8] Hamilton M. Developing clinical standards and accrediting clinics in infertility care. Hum Fertil (Camb) 2003;6(Suppl. 1):S30—2. [9] Pierik FH, Van Ginneken AM, Dohle GR, Vreeburg JT, Weber RF. The advantages of standardized evaluation of male infertility. Int J Androl 2000;23:340—6. [10] Jequier AM. The importance of diagnosis in the clinical management of infertility in the male. Reprod Biomed Online 2006;13:331—5. [11] Jequier AM. Clinical andrology — still a major problem in the treatment of infertility. Hum Reprod 2004;19:1245—9. [12] Kliesch S. Continuing medical education in andrology: continuing education between wish and reality. Urologe A 2010;49:930—3. [13] Andrich DE, Mundy AR. A Fellowship programme in reconstructive urological surgery: what is it and what is it for? BJU Int 2010;106:108—11.
Available online at www.sciencedirect.com