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 (
