Lapse in embryo transfer training does not negatively affect clinical pregnancy rates for reproductive endocrinology and infertility fellows Jessica Kresowik, M.D., Amy Sparks, Ph.D., Eyup H. Duran, M.D., and Divya K. Shah, M.D. Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
Objective: To compare rates of clinical pregnancy (CPR) and live birth (LBR) following embryo transfer (ET) performed by reproductive endocrinology and infertility (REI) fellows before and after a prolonged lapse in clinical training due to an 18-month research rotation. Design: Retrospective cohort study. Setting: Not applicable. Patient(s): All women undergoing in vitro fertilization (IVF) and IVF–intracytoplasmic sperm injection (ICSI) cycles with ET performed by REI fellows from August 2003 to July 2012. Intervention: Eighteen-month lapse in clinical training of REI fellows. Main Outcome Measure(s): CPR and LBR before and after the lapse in clinical training were calculated and compared per fellow and as a composite group. Alternating logistic regression models were used to calculate the odds of clinical pregnancy and live birth following transfers performed before and after the lapse in training. Result(s): Unadjusted odds of clinical pregnancy and live birth were similar between the two time periods both for individual fellows and for the composite group. Alternate logistic regression analysis revealed no significant difference in CPR (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.83–1.07) or LBR (OR 1.05, 95% CI 0.94–1.18) after the lapse in training compared with before. Conclusion(s): A research rotation is common in REI fellowship training programs. This prolonged departure from clinical training does not appear to negatively affect pregnancy outcome Use your smartphone following fellow ET. (Fertil SterilÒ 2015;103:728–33. Ó2015 by American Society for Reproto scan this QR code ductive Medicine.) and connect to the Key Words: Embryo transfer, training, lapse, REI, fellows Discuss: You can discuss this article with its authors and with other ASRM members at http:// fertstertforum.com/kresowikj-lapse-embryo-transfer-rei-fellows/
E
mbryo transfer (ET) is a nuanced part of the in vitro fertilization (IVF) process, where success is affected by both provider technique and experience (1, 2). Factors thought
to be associated with implantation following ET include the use of soft versus rigid transfer catheters and provider perception of the ease of transfer (3–5). Avoiding negative
Received September 8, 2014; revised and accepted December 5, 2014; published online December 31, 2014. J.K. has nothing to disclose. A.S. has nothing to disclose. E.H.D. has nothing to disclose. D.K.S. has nothing to disclose. Presented at the 69th American Society for Reproductive Medicine Annual Meeting, Boston, Massachusetts, October 12-17, 2013. Reprint requests: Divya K. Shah, M.D., Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, 31324 PFP, 200 Hawkins Drive, Iowa City, Iowa 52242 (E-mail: [email protected]). Fertility and Sterility® Vol. 103, No. 3, March 2015 0015-0282/$36.00 Copyright ©2015 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2014.12.102 728
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.
pressure when removing the catheter as well as maintaining a controlled velocity when depressing the plunger also have been associated with success (6). It is expected that reproductive endocrinology and infertility (REI) fellowship programs ensure adequate training and competence in ET, although the best training modality and the time required to accomplish this goal are not well understood. The number of ETs required to reach proficiency has been shown to vary greatly between studies as well as VOL. 103 NO. 3 / MARCH 2015
Fertility and Sterility® between individual learners, with estimates ranging from 15 to 100 ETs (7–10). In addition, the implementation of a formalized training program using intrauterine insemination did not appear to improve a learner's time to proficiency compared with those who did not undergo similar training (8). A further complicating factor in the ET training process for many REI fellowship programs in the United States is the requirement for 18 months of dedicated research time. This ‘‘research block’’ is frequently scheduled during the 2nd year of fellowship and removes fellows from participation in patient care. The effect of this prolonged lapse in clinical training on success rates after ET remains unknown. We sought to evaluate the impact of a lapse in training on clinical pregnancy rate (CPR) and live birth rate (LBR) following ET performed by REI fellows.
MATERIALS AND METHODS Study Population Data were retrospectively queried from the University of Iowa's IVF database from August 2003 till July 2012. A total of five fellows started and completed their training during the study time period. All IVF and IVF–intracytoplasmic sperm injection (ICSI) cycles with ET performed by REI fellows during this time period were included. It is institutional practice for 1st-year fellows to observe ETs for 1 month and then perform all subsequent ETs when covering the IVF service. The database does not reliably track the number of ETs initiated by fellows but ultimately taken over by attending physicians, so these transfers were excluded from analysis. Embryo transfers were performed in the IVF procedure room without analgesia. The cervix was gently cleansed with warm saline solution and any excess cervical mucus was aspirated. A mock ET was first performed with the use of a Wallace Trial Catheter (Smiths Medical) to ensure passage through the internal cervical os. If passage of the catheter required significant manipulation, the ‘‘afterload’’ method with retention of the outer sheath was used at the discretion of the transferring provider (11). If a fellow was unable to successfully pass the mock transfer catheter after a reasonable attempt, the transfer was performed by the supervising physician. Once the mock ET was complete, embryos were loaded into either a Wallace Classic Embryo Replacement Catheter (August 2003–June 2004) or Wallace Sure View Embryo Replacement Catheter (June 2004 and subsequently) for transfer. Transfer catheters were loaded with a solid column of culture medium, followed by 5 mL air, 20 mL medium containing the embryo(s), and a final 5 mL air. All ETs (including mock ETs) were performed under transabdominal ultrasound guidance provided either by the supervising faculty physician or a trained sonographer. All patients signed consents for data collection and quality assurance analysis at the start of treatment. The University of Iowa Institutional Review Board deemed the project to be exempt from further review because of the noninterventional and quality assurance nature of the study. VOL. 103 NO. 3 / MARCH 2015
Exposure and Outcome Variables The exposure was an 18-month lapse in clinical training while on a research rotation. Fellow ETs were divided into two groups: those performed before (pre-lapse) and after (post-lapse) the 18-month departure from clinical training. The primary outcome was CPR per ET (defined as the presence of an intrauterine gestational sac on ultrasound). The secondary outcome was LBR per ET (defined as the birth of an infant at or beyond 20 weeks gestation).
Potential Confounding Variables Patient demographic variables, including female age, body mass index (BMI), race, antral follicle count (AFC), and infertility diagnosis, were noted in the medical record at the time of cycle initiation. Race was classified as white, African-American, Asian, multiracial, or other by the nurse or providing physician. Categories of infertility diagnosis included male factor, tubal factor, ovulatory dysfunction, endometriosis, uterine factor, and diminished ovarian reserve. IVF cycle characteristics, including cycle number (1, 2, 3, R4), use of donor oocytes, use of ICSI, total gonadotropin dosage (IU of FSH or hMG), use of fresh versus frozen embryos, number of embryos transferred (1, 2, R3), and day 3 versus day 5 ET, were recorded in the IVF database on a per-cycle basis. Additional variables reported include numbers of ETs complicated by either retention of one or more embryos in the catheter after initial transfer attempt or the need to temporarily return the catheter to the embryologist because of prolonged difficulty in gaining entry into the uterine cavity.
Statistical Analysis Descriptive statistics were used to assess the demographics of the study population. CPR and LBR per ET performed after the training lapse were compared with CPR and LBR per ET performed before the training lapse by means of the Cochran-Mantel Haenszel method, controlling for the fellow that performed the ET. This same comparison was made for each individual fellow with the use of the Pearson chisquare test, generating unadjusted odds ratios (ORs). A generalized linear model was used to test for the effect of training lapse on CPR after adjusting for potential confounding variables. This model was fitted by the alternating logistic regression algorithm to account for the association of transfer outcome in subjects treated by the same fellow as well for repeated ETs in the same subject. Female age, cycle number, use of donor eggs, fresh versus frozen cycle, and day 3 versus day 5 transfer were included a priori as covariates in the model; other potential confounders were examined but did not change effect estimates by >10% and were therefore not included in the final model.
RESULTS Five fellows completed their training from August 2003 to July 2012. A total of 793 patients and 933 ETs were included in the study. Demographic and IVF cycle characteristics of the study population are listed in Table 1. Patient age, ethnicity, 729
ORIGINAL ARTICLE: ASSISTED REPRODUCTION
TABLE 1 Patient and cycle characteristics for embryo transfers performed by reproductive endocrinology and infertility fellows before and after an 18-mo lapse in clinical training. Characteristic
Pre-lapse group (n [ 378)
Patient Age (y), mean (SD) 33.7 (5.0) White 315 (91) BMI (kg/m2) 10 days in embryo transfer to have a negative impact on pregnancy rate (9). This result may be different from our study due to their definition of pregnancy by hCG level rather than clinical intrauterine pregnancy as in our study. It should also be noted that this study included a very unusual patient population in that 40%–70% were the recipients of donor oocytes; this may limit the generalizability of the results to other populations (9). In summary, an 18-month lapse in clinical training appears to have no effect on rates of clinical pregnancy and live birth following ET performed by REI fellows. The findings of this study have implications not only for training programs with an educational structure similar to our own, but also for those that schedule a research block at the end of fellowship, when the lapse in clinical training would fall immediately before a fellow's transition to independent practice. Although our study design precludes us from specifically commenting on the impact of shorter lapses in clinical care on ET proficiency, the absence of skill attrition after an 18month lapse suggests that shorter lapses may also be of limited consequence. The latter situation may be relevant to lower-volume practices where an individual practitioner may not perform ET for a few months, or to academic centers where research commitments may preclude some faculty members from engaging in consistent coverage of the IVF service. The overall absence of skill decay after an 18month lapse in clinical training should be reassuring to training programs attempting to incorporate fellow ET into their curriculum. ET is accepted to be a critical step in the success of IVF cycles, and a concerted effort by REI training programs to educate fellows with hands-on experience should be forthcoming.
REFERENCES 1. 2.
3.
4. 5.
Mains L, Van Voorhis BJ. Optimizing the technique of embryo transfer. Fertil Steril 2010;94:785–90. Hearns-Stokes RM, Miller BT, Scott L, Creuss D, Chakraborty PK, Segars JH. Pregnancy rates after embryo transfer depend on the provider at embryo transfer. Fertil Steril 2000;74:80–6. Abou-Setta AM, Al-Inany HG, Mansour RT, Serour GI, Aboulghar MA. Soft versus firm embryo transfer catheters for assisted reproduction: a systematic review and meta-analysis. Hum Reprod 2005;20:3114–21. Buckett WM. A review and meta-analysis of prospective trials comparing different catheters used for embryo transfer. Fertil Steril 2006;85:728–34. Tomas C, Tikkinen K, Tuomivaara L, Tapanainen JS, Martikainen H. The degree of difficulty of embryo transfer is an independent factor for predicting pregnancy. Hum Reprod 2002;17:2632–5. VOL. 103 NO. 3 / MARCH 2015
Fertility and Sterility® 6.
Grygoruk C, Ratomski K, Kolodziejczyk M, Gagan J, Modlinski JA, Gajda B, et al. Fluid dynamics during embryo transfer. Fertil Steril 2011;96:324–7. 7. Dessolle L, Freour T, Barriere P, Jean M, Ravel C, Darai E, et al. How soon can I be proficient in embryo transfer? Lessons from the cumulative summation test for learning curve (LC-CUSUM). Hum Reprod 2010;25:380–6. 8. 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. 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. 10. Papageorgiou TC, Hearns-Stokes RM, Leondires MP, Miller BT, Chakraborty P, Cruess D, et al. Training of providers in embryo transfer:
VOL. 103 NO. 3 / MARCH 2015
11.
12. 13.
14. 15.
what is the minimum number of transfers required for proficiency? Hum Reprod 2001;16:1415–9. Neithardt AB, Segars JH, Hennessy S, James AN, McKeeby JL. Embryo afterloading: a refinement in embryo transfer technique that may increase clinical pregnancy. Fertil Steril 2005;83:710–4. Perez RS, Skinner A, Weyhrauch P, Niehaus J, Lathan C, Schwaitzberg SD, et al. Prevention of surgical skill decay. Mil Med 2013;178:76–86. Willis Ross E, Van Sickle Kent R, Peterson Richard M. Impact of non-clinical years on surgery residents' technical skills: evaluation of a technical skills refresher curriculum. Surg Sci 2013;4:131–4. Wittenberger MD, Catherino WH, Armstrong AY. Role of embryo transfer in fellowship training. Fertil Steril 2007;88:1014–5. Bishop L, Brezina PR, Segars J. Training in embryo transfer: how should it be done? Fertil Steril 2013;100:351–2.
733
ORIGINAL ARTICLE: ASSISTED REPRODUCTION
SUPPLEMENTAL TABLE 1 Clinical pregnancy rate per embryo transfer for REI fellows based on the total number of embryo transfers performed immediately before and after an 18-month lapse in clinical training. All ETs
Last 50 ETs
Last 25 ETs
Fellow Pre-lapse Post-lapse Pre-lapse Post-lapse Pre-lapse Post-lapse 1 2 3 4 5
64 65 53 56 59
63 59 57 53 57
66 64 50 52 59a
58 56 54 48 52
68 68 56 56 60
64 56 56 48 40
Note: Results are presented as percent unadjusted mean CPR per embryo transfer. CPR ¼ clinical pregnancy rate; ET ¼ embryo transfer. a Fellow performed only 32 transfers before the lapse. Kresowik. Lapse in embryo transfer training. Fertil Steril 2015.
733.e1
VOL. 103 NO. 3 / MARCH 2015
Fertility and Sterility®
SUPPLEMENTAL TABLE 2 Quantification of embryo transfer difficulty for REI fellows before and after an 18-month lapse in clinical training. Pre-lapse Fellow 1 2 3 4 5
Post-lapse
No. ETs
Retained
Reloaded
Attending took over
No. ETs
Retained
Reloaded
Attending took over
55 91 104 96 32
1 0 3 2 0
0 1 1 3 0
1 0 0 2 0
80 168 98 135 74
1 0 2 1 0
0 2 1 2 0
1 0 1 1 1
Note: Retained ¼ transfers in which one or more embryos were noted to be retained in the catheter after initial attempt; reloaded ¼ transfers in which embryos were temporarily returned to the embryologist owing to prolonged difficulty in gaining entry into the uterine cavity; attending took over ¼ transfers initiated by a fellow but ultimately completed by an attending physician. Abbreviations as in Supplemental Table 1. Kresowik. Lapse in embryo transfer training. Fertil Steril 2015.
VOL. 103 NO. 3 / MARCH 2015
733.e2
Objective: To compare rates of clinical pregnancy (CPR) and live birth (LBR) following embryo transfer (ET) performed by reproductive endocrinology and infertility (REI) fellows before and after a prolonged lapse in clinical training due to an 18-month research rotation. Design: Retrospective cohort study. Setting: Not applicable. Patient(s): All women undergoing in vitro fertilization (IVF) and IVF–intracytoplasmic sperm injection (ICSI) cycles with ET performed by REI fellows from August 2003 to July 2012. Intervention: Eighteen-month lapse in clinical training of REI fellows. Main Outcome Measure(s): CPR and LBR before and after the lapse in clinical training were calculated and compared per fellow and as a composite group. Alternating logistic regression models were used to calculate the odds of clinical pregnancy and live birth following transfers performed before and after the lapse in training. Result(s): Unadjusted odds of clinical pregnancy and live birth were similar between the two time periods both for individual fellows and for the composite group. Alternate logistic regression analysis revealed no significant difference in CPR (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.83–1.07) or LBR (OR 1.05, 95% CI 0.94–1.18) after the lapse in training compared with before. Conclusion(s): A research rotation is common in REI fellowship training programs. This prolonged departure from clinical training does not appear to negatively affect pregnancy outcome Use your smartphone following fellow ET. (Fertil SterilÒ 2015;103:728–33. Ó2015 by American Society for Reproto scan this QR code ductive Medicine.) and connect to the Key Words: Embryo transfer, training, lapse, REI, fellows Discuss: You can discuss this article with its authors and with other ASRM members at http:// fertstertforum.com/kresowikj-lapse-embryo-transfer-rei-fellows/
E
mbryo transfer (ET) is a nuanced part of the in vitro fertilization (IVF) process, where success is affected by both provider technique and experience (1, 2). Factors thought
to be associated with implantation following ET include the use of soft versus rigid transfer catheters and provider perception of the ease of transfer (3–5). Avoiding negative
Received September 8, 2014; revised and accepted December 5, 2014; published online December 31, 2014. J.K. has nothing to disclose. A.S. has nothing to disclose. E.H.D. has nothing to disclose. D.K.S. has nothing to disclose. Presented at the 69th American Society for Reproductive Medicine Annual Meeting, Boston, Massachusetts, October 12-17, 2013. Reprint requests: Divya K. Shah, M.D., Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, 31324 PFP, 200 Hawkins Drive, Iowa City, Iowa 52242 (E-mail: [email protected]). Fertility and Sterility® Vol. 103, No. 3, March 2015 0015-0282/$36.00 Copyright ©2015 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2014.12.102 728
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.
pressure when removing the catheter as well as maintaining a controlled velocity when depressing the plunger also have been associated with success (6). It is expected that reproductive endocrinology and infertility (REI) fellowship programs ensure adequate training and competence in ET, although the best training modality and the time required to accomplish this goal are not well understood. The number of ETs required to reach proficiency has been shown to vary greatly between studies as well as VOL. 103 NO. 3 / MARCH 2015
Fertility and Sterility® between individual learners, with estimates ranging from 15 to 100 ETs (7–10). In addition, the implementation of a formalized training program using intrauterine insemination did not appear to improve a learner's time to proficiency compared with those who did not undergo similar training (8). A further complicating factor in the ET training process for many REI fellowship programs in the United States is the requirement for 18 months of dedicated research time. This ‘‘research block’’ is frequently scheduled during the 2nd year of fellowship and removes fellows from participation in patient care. The effect of this prolonged lapse in clinical training on success rates after ET remains unknown. We sought to evaluate the impact of a lapse in training on clinical pregnancy rate (CPR) and live birth rate (LBR) following ET performed by REI fellows.
MATERIALS AND METHODS Study Population Data were retrospectively queried from the University of Iowa's IVF database from August 2003 till July 2012. A total of five fellows started and completed their training during the study time period. All IVF and IVF–intracytoplasmic sperm injection (ICSI) cycles with ET performed by REI fellows during this time period were included. It is institutional practice for 1st-year fellows to observe ETs for 1 month and then perform all subsequent ETs when covering the IVF service. The database does not reliably track the number of ETs initiated by fellows but ultimately taken over by attending physicians, so these transfers were excluded from analysis. Embryo transfers were performed in the IVF procedure room without analgesia. The cervix was gently cleansed with warm saline solution and any excess cervical mucus was aspirated. A mock ET was first performed with the use of a Wallace Trial Catheter (Smiths Medical) to ensure passage through the internal cervical os. If passage of the catheter required significant manipulation, the ‘‘afterload’’ method with retention of the outer sheath was used at the discretion of the transferring provider (11). If a fellow was unable to successfully pass the mock transfer catheter after a reasonable attempt, the transfer was performed by the supervising physician. Once the mock ET was complete, embryos were loaded into either a Wallace Classic Embryo Replacement Catheter (August 2003–June 2004) or Wallace Sure View Embryo Replacement Catheter (June 2004 and subsequently) for transfer. Transfer catheters were loaded with a solid column of culture medium, followed by 5 mL air, 20 mL medium containing the embryo(s), and a final 5 mL air. All ETs (including mock ETs) were performed under transabdominal ultrasound guidance provided either by the supervising faculty physician or a trained sonographer. All patients signed consents for data collection and quality assurance analysis at the start of treatment. The University of Iowa Institutional Review Board deemed the project to be exempt from further review because of the noninterventional and quality assurance nature of the study. VOL. 103 NO. 3 / MARCH 2015
Exposure and Outcome Variables The exposure was an 18-month lapse in clinical training while on a research rotation. Fellow ETs were divided into two groups: those performed before (pre-lapse) and after (post-lapse) the 18-month departure from clinical training. The primary outcome was CPR per ET (defined as the presence of an intrauterine gestational sac on ultrasound). The secondary outcome was LBR per ET (defined as the birth of an infant at or beyond 20 weeks gestation).
Potential Confounding Variables Patient demographic variables, including female age, body mass index (BMI), race, antral follicle count (AFC), and infertility diagnosis, were noted in the medical record at the time of cycle initiation. Race was classified as white, African-American, Asian, multiracial, or other by the nurse or providing physician. Categories of infertility diagnosis included male factor, tubal factor, ovulatory dysfunction, endometriosis, uterine factor, and diminished ovarian reserve. IVF cycle characteristics, including cycle number (1, 2, 3, R4), use of donor oocytes, use of ICSI, total gonadotropin dosage (IU of FSH or hMG), use of fresh versus frozen embryos, number of embryos transferred (1, 2, R3), and day 3 versus day 5 ET, were recorded in the IVF database on a per-cycle basis. Additional variables reported include numbers of ETs complicated by either retention of one or more embryos in the catheter after initial transfer attempt or the need to temporarily return the catheter to the embryologist because of prolonged difficulty in gaining entry into the uterine cavity.
Statistical Analysis Descriptive statistics were used to assess the demographics of the study population. CPR and LBR per ET performed after the training lapse were compared with CPR and LBR per ET performed before the training lapse by means of the Cochran-Mantel Haenszel method, controlling for the fellow that performed the ET. This same comparison was made for each individual fellow with the use of the Pearson chisquare test, generating unadjusted odds ratios (ORs). A generalized linear model was used to test for the effect of training lapse on CPR after adjusting for potential confounding variables. This model was fitted by the alternating logistic regression algorithm to account for the association of transfer outcome in subjects treated by the same fellow as well for repeated ETs in the same subject. Female age, cycle number, use of donor eggs, fresh versus frozen cycle, and day 3 versus day 5 transfer were included a priori as covariates in the model; other potential confounders were examined but did not change effect estimates by >10% and were therefore not included in the final model.
RESULTS Five fellows completed their training from August 2003 to July 2012. A total of 793 patients and 933 ETs were included in the study. Demographic and IVF cycle characteristics of the study population are listed in Table 1. Patient age, ethnicity, 729
ORIGINAL ARTICLE: ASSISTED REPRODUCTION
TABLE 1 Patient and cycle characteristics for embryo transfers performed by reproductive endocrinology and infertility fellows before and after an 18-mo lapse in clinical training. Characteristic
Pre-lapse group (n [ 378)
Patient Age (y), mean (SD) 33.7 (5.0) White 315 (91) BMI (kg/m2) 10 days in embryo transfer to have a negative impact on pregnancy rate (9). This result may be different from our study due to their definition of pregnancy by hCG level rather than clinical intrauterine pregnancy as in our study. It should also be noted that this study included a very unusual patient population in that 40%–70% were the recipients of donor oocytes; this may limit the generalizability of the results to other populations (9). In summary, an 18-month lapse in clinical training appears to have no effect on rates of clinical pregnancy and live birth following ET performed by REI fellows. The findings of this study have implications not only for training programs with an educational structure similar to our own, but also for those that schedule a research block at the end of fellowship, when the lapse in clinical training would fall immediately before a fellow's transition to independent practice. Although our study design precludes us from specifically commenting on the impact of shorter lapses in clinical care on ET proficiency, the absence of skill attrition after an 18month lapse suggests that shorter lapses may also be of limited consequence. The latter situation may be relevant to lower-volume practices where an individual practitioner may not perform ET for a few months, or to academic centers where research commitments may preclude some faculty members from engaging in consistent coverage of the IVF service. The overall absence of skill decay after an 18month lapse in clinical training should be reassuring to training programs attempting to incorporate fellow ET into their curriculum. ET is accepted to be a critical step in the success of IVF cycles, and a concerted effort by REI training programs to educate fellows with hands-on experience should be forthcoming.
REFERENCES 1. 2.
3.
4. 5.
Mains L, Van Voorhis BJ. Optimizing the technique of embryo transfer. Fertil Steril 2010;94:785–90. Hearns-Stokes RM, Miller BT, Scott L, Creuss D, Chakraborty PK, Segars JH. Pregnancy rates after embryo transfer depend on the provider at embryo transfer. Fertil Steril 2000;74:80–6. Abou-Setta AM, Al-Inany HG, Mansour RT, Serour GI, Aboulghar MA. Soft versus firm embryo transfer catheters for assisted reproduction: a systematic review and meta-analysis. Hum Reprod 2005;20:3114–21. Buckett WM. A review and meta-analysis of prospective trials comparing different catheters used for embryo transfer. Fertil Steril 2006;85:728–34. Tomas C, Tikkinen K, Tuomivaara L, Tapanainen JS, Martikainen H. The degree of difficulty of embryo transfer is an independent factor for predicting pregnancy. Hum Reprod 2002;17:2632–5. VOL. 103 NO. 3 / MARCH 2015
Fertility and Sterility® 6.
Grygoruk C, Ratomski K, Kolodziejczyk M, Gagan J, Modlinski JA, Gajda B, et al. Fluid dynamics during embryo transfer. Fertil Steril 2011;96:324–7. 7. Dessolle L, Freour T, Barriere P, Jean M, Ravel C, Darai E, et al. How soon can I be proficient in embryo transfer? Lessons from the cumulative summation test for learning curve (LC-CUSUM). Hum Reprod 2010;25:380–6. 8. 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. 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. 10. Papageorgiou TC, Hearns-Stokes RM, Leondires MP, Miller BT, Chakraborty P, Cruess D, et al. Training of providers in embryo transfer:
VOL. 103 NO. 3 / MARCH 2015
11.
12. 13.
14. 15.
what is the minimum number of transfers required for proficiency? Hum Reprod 2001;16:1415–9. Neithardt AB, Segars JH, Hennessy S, James AN, McKeeby JL. Embryo afterloading: a refinement in embryo transfer technique that may increase clinical pregnancy. Fertil Steril 2005;83:710–4. Perez RS, Skinner A, Weyhrauch P, Niehaus J, Lathan C, Schwaitzberg SD, et al. Prevention of surgical skill decay. Mil Med 2013;178:76–86. Willis Ross E, Van Sickle Kent R, Peterson Richard M. Impact of non-clinical years on surgery residents' technical skills: evaluation of a technical skills refresher curriculum. Surg Sci 2013;4:131–4. Wittenberger MD, Catherino WH, Armstrong AY. Role of embryo transfer in fellowship training. Fertil Steril 2007;88:1014–5. Bishop L, Brezina PR, Segars J. Training in embryo transfer: how should it be done? Fertil Steril 2013;100:351–2.
733
ORIGINAL ARTICLE: ASSISTED REPRODUCTION
SUPPLEMENTAL TABLE 1 Clinical pregnancy rate per embryo transfer for REI fellows based on the total number of embryo transfers performed immediately before and after an 18-month lapse in clinical training. All ETs
Last 50 ETs
Last 25 ETs
Fellow Pre-lapse Post-lapse Pre-lapse Post-lapse Pre-lapse Post-lapse 1 2 3 4 5
64 65 53 56 59
63 59 57 53 57
66 64 50 52 59a
58 56 54 48 52
68 68 56 56 60
64 56 56 48 40
Note: Results are presented as percent unadjusted mean CPR per embryo transfer. CPR ¼ clinical pregnancy rate; ET ¼ embryo transfer. a Fellow performed only 32 transfers before the lapse. Kresowik. Lapse in embryo transfer training. Fertil Steril 2015.
733.e1
VOL. 103 NO. 3 / MARCH 2015
Fertility and Sterility®
SUPPLEMENTAL TABLE 2 Quantification of embryo transfer difficulty for REI fellows before and after an 18-month lapse in clinical training. Pre-lapse Fellow 1 2 3 4 5
Post-lapse
No. ETs
Retained
Reloaded
Attending took over
No. ETs
Retained
Reloaded
Attending took over
55 91 104 96 32
1 0 3 2 0
0 1 1 3 0
1 0 0 2 0
80 168 98 135 74
1 0 2 1 0
0 2 1 2 0
1 0 1 1 1
Note: Retained ¼ transfers in which one or more embryos were noted to be retained in the catheter after initial attempt; reloaded ¼ transfers in which embryos were temporarily returned to the embryologist owing to prolonged difficulty in gaining entry into the uterine cavity; attending took over ¼ transfers initiated by a fellow but ultimately completed by an attending physician. Abbreviations as in Supplemental Table 1. Kresowik. Lapse in embryo transfer training. Fertil Steril 2015.
VOL. 103 NO. 3 / MARCH 2015
733.e2
