Who are we? A perspective on the reproductive endocrinologist and infertility specialist in the 21st century Reproductive endocrinology and infertility (REI) evolved as a subspecialty of obstetrics and gynecology to foster expertise in the scientific underpinnings and clinical applications of all reproductive disorders. Indeed, as mandated by the American Board of Obstetrics and Gynecology (ABOG), graduates of REI fellowships are expected to become experts in diverse areas ranging from the understanding of the complexities of menstrual cycle physiology to dealing with anatomic and functional disorders related to menstrual cyclicity, fertility, and the ability to maintain a pregnancy. Moreover, approved training programs must provide adequate surgical volume to gain the necessary surgical skills to treat myomas, endometriosis, and other anatomic disorders. In the companion Inklings contribution by Drs. Barnhart and DeCherney there is a disturbing portrayal of the specialty of REI. We see this as a call to action. We don't disagree that REI specialists no longer follow their patients to delivery as obstetricians, but understanding placentation and pregnancy loss, considered the purview of the obstetrician, are key issues for the REI. In fact, as we become better at identifying the optimal embryo for transfer, the factors that interfere with implantation and/or lead to pregnancy loss, in the absence of aneuploidy, will become increasingly important. Further, we disagree that we have lost so much of the practice of gynecology that we can no longer be considered gynecologists. Drs. Barnhart and DeCherney state, ‘‘We are no longer specialists or consultants in menopause, family planning, adolescent medicine, or minimally invasive surgery.’’ While it is true there are now separate training programs in these last three domains, it is not true that the training in REI does not (or should not) include these areas. To further bolster their position, Drs. Barnhart and DeCherney present data from a workforce and practice survey that concluded ‘‘current training has ‘‘a surplus’’ of reproductive surgery and basic research, and not enough time devoted to male infertility, embryology, embryo transfer, and genetics.’’ REI as a specialty has witnessed dramatic changes—the most significant of which was the introduction of in vitro fertilization (IVF) as a key treatment strategy. An REI who is not proficient at IVF will not be capable of delivering the most effective infertility treatment available and indeed would have difficulty securing a position in either private practice or academics. IVF is an incredible tool; it is unfortunate that many believe its existence should result in a decreased interest and focus on endocrinology. In fact, we argue that having a strong background in endocrinology is needed for understanding gamete biology, optimizing IVF stimulation protocols, and understanding the ingredients needed for a truly successful IVF program. The tendency to describe ourselves as ‘‘technicians’’ who follow ‘‘cookbook’’ algorithms should be supplanted; we should instead view ourselves as specialists who develop novel treatment options based on sound endocrinologic training. Although in some instances the focus on infertility and IVF has led practice pat26
terns to default to medical endocrinologists and to maternalfetal medicine specialists, the unique experience of an REI specialist for dealing with polycystic ovarian syndrome, menopause, and recurrent pregnancy loss should be fostered both in the research and clinical arenas. The second major change in REI is research-based. While a reduction in federal funding has impacted all fields, REI has been particularly negatively affected. To remain competitive, physician-scientists must spend a greater percentage of their time in the laboratory. Further, embryo research funding is banned at the federal level, limiting research in an area for which we are uniquely trained and which holds special importance in our field. As funds and interest in clinical and translational research have increased globally, REI fellowships largely still seem to focus on basic science to provide materials for the fellowship thesis. This fails to recognize the significant contributions of clinically active physicians in research, clinical care, and teaching, thus contributing to an exodus of young physicians from academic REI programs. Moreover, clinically focused physicians interested in research and an academic career frequently neither develop the skills nor feel rewarded for working in those areas where their clinical knowledge might fuel translational research and innovation. If the old model of REI and academics that focuses only on benchtop science continues, the ease of practicing IVF in the private sector, as well as the financial rewards of this practice, makes the move to the private sector a ‘‘no-brainer’’ for many. So where do we go from here? REI is, and has always been, an incredible specialty that integrates critical thinking with the need for technical skills. Additionally, it is the only specialty where the clinic and the lab are so highly integrated that they cannot function independently. This leads to significant opportunities (and materials) to foster research. But without the proper basic understanding of endocrinology, embryology, genetics, epigenetics, and placental biology, this opportunity is wasted. Additionally, we are increasingly appreciating the importance of the endogenous and exogenous environmental factors on health and the opportunity to study their impact in the pre-pregnancy and pregnancy timeframe. Our ability to affect the next generation in profound ways cannot be underestimated. In fact, reproductive medicine, which encompasses all of the elements of the beginning of life, really defines all of medicine and surgery. So, perhaps, saying we're still gynecologists is too limiting.. The field of REI is most definitely changing, but it is expanding, not constricting. We need to look beyond the pregnancy rate to the health of the pregnancy and the life-long health of the child. To understand these critical areas, we need a strong foundation in basic endocrinology, developmental biology and molecular genetics. We absolutely should have more training for fellows in embryology and male infertility but these areas require a firm grasp of male and female endocrinology, developmental biology, and anatomy. So where does this take our specialty? It may be true, as Drs. Barnhart and DeCherney state, that an REI needs to know, ‘‘.more and more about less and less.’’—but when does this focus begin? What foundational knowledge is VOL. 104 NO. 1 / JULY 2015
Fertility and Sterility® required prior to delving into the detailed study of embryology, male infertility, or ovulation induction? How can we appropriately understand these areas and expect to not only master then but mold them for the future, without foundational knowledge. Even to optimize success rates with IVF (if success if the birth of a healthy child setup for a healthy life), we'll need to understand ovarian aging (ultimately leading to menopause), metabolic health (of the polycystic ovarian syndrome patient), surgical management (indications, risk, optimization for endometriosis, and uterine fibroids) and more. What about the need to understand adolescent health, endocrinology and reproduction for the purposes of fertility preservation in young patients with cancer? Training is a time to be exposed to the depth and breadth of our specialty. This foundational training will provide a practicing REI with the skills to make complex decisions, ask the right questions and give the best care, even if their ultimate practice becomes more focused. And optimization of training will also provide the foundation for those members of our specialty who will continue to move the field forward, to make the major advances that will improve health for women, men, and children.doesn't sound narrow to us. Drs. Barnhart and DeCherney suggest that the advent of IVF as, ‘‘the ultimate treatment to address all types of infertility,’’ has decreased the use of surgical approaches and has weakened our subspecialty, removing REIs from the ranks of gynecologists. While it is true that many who practice ‘‘IVF’’ often elect to refer their surgical patients, this does not mean that as a specialty, we have given or should give up our gynecologic practice to others. One must underscore that there is a difference between the experts who elect to specialize in IVF and others who continue to practice the art of reproductive medicine. REIs are experts in reproductive endocrinology, family planning, adolescent medicine, and minimally invasive surgery. Indeed, the development of IVF is but an example of how expertise and insight into the
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reproductive processes—both basic physiology and understanding the subtleties of follicular developments—has led to the very optimization of this treatment modality. This could not have happened without the melding of expert reproductive endocrinologists and superb surgeons. One cannot divorce the subtle endocrine events of follicular developments from follicular growth observed on ultrasound. Indeed, the best IVF practice requires profound understanding of menstrual cycle dynamics, which may not be appreciated by those not involved in our specialty. Irrespective of workforce and practice surveys, forward-thinking reproductive endocrine leaders must foster innovations and training in endocrinology, reproductive surgery, embryology, reproductive biology, and genetics.
Marcelle I. Cedars, M.D.a Zev Rosenwaks, M.D.b a Department of Obstetrics, Gynecology and Reproductive Sciences, University of California—San Francisco, San Francisco, California; and b The Ronald O. Perelman & Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, New York http://dx.doi.org/10.1016/j.fertnstert.2015.05.034 You can discuss this article with its authors and with other ASRM members at http://fertstertforum.com/cedarsm-subspecialist-reigynecology/ 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.
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terns to default to medical endocrinologists and to maternalfetal medicine specialists, the unique experience of an REI specialist for dealing with polycystic ovarian syndrome, menopause, and recurrent pregnancy loss should be fostered both in the research and clinical arenas. The second major change in REI is research-based. While a reduction in federal funding has impacted all fields, REI has been particularly negatively affected. To remain competitive, physician-scientists must spend a greater percentage of their time in the laboratory. Further, embryo research funding is banned at the federal level, limiting research in an area for which we are uniquely trained and which holds special importance in our field. As funds and interest in clinical and translational research have increased globally, REI fellowships largely still seem to focus on basic science to provide materials for the fellowship thesis. This fails to recognize the significant contributions of clinically active physicians in research, clinical care, and teaching, thus contributing to an exodus of young physicians from academic REI programs. Moreover, clinically focused physicians interested in research and an academic career frequently neither develop the skills nor feel rewarded for working in those areas where their clinical knowledge might fuel translational research and innovation. If the old model of REI and academics that focuses only on benchtop science continues, the ease of practicing IVF in the private sector, as well as the financial rewards of this practice, makes the move to the private sector a ‘‘no-brainer’’ for many. So where do we go from here? REI is, and has always been, an incredible specialty that integrates critical thinking with the need for technical skills. Additionally, it is the only specialty where the clinic and the lab are so highly integrated that they cannot function independently. This leads to significant opportunities (and materials) to foster research. But without the proper basic understanding of endocrinology, embryology, genetics, epigenetics, and placental biology, this opportunity is wasted. Additionally, we are increasingly appreciating the importance of the endogenous and exogenous environmental factors on health and the opportunity to study their impact in the pre-pregnancy and pregnancy timeframe. Our ability to affect the next generation in profound ways cannot be underestimated. In fact, reproductive medicine, which encompasses all of the elements of the beginning of life, really defines all of medicine and surgery. So, perhaps, saying we're still gynecologists is too limiting.. The field of REI is most definitely changing, but it is expanding, not constricting. We need to look beyond the pregnancy rate to the health of the pregnancy and the life-long health of the child. To understand these critical areas, we need a strong foundation in basic endocrinology, developmental biology and molecular genetics. We absolutely should have more training for fellows in embryology and male infertility but these areas require a firm grasp of male and female endocrinology, developmental biology, and anatomy. So where does this take our specialty? It may be true, as Drs. Barnhart and DeCherney state, that an REI needs to know, ‘‘.more and more about less and less.’’—but when does this focus begin? What foundational knowledge is VOL. 104 NO. 1 / JULY 2015
Fertility and Sterility® required prior to delving into the detailed study of embryology, male infertility, or ovulation induction? How can we appropriately understand these areas and expect to not only master then but mold them for the future, without foundational knowledge. Even to optimize success rates with IVF (if success if the birth of a healthy child setup for a healthy life), we'll need to understand ovarian aging (ultimately leading to menopause), metabolic health (of the polycystic ovarian syndrome patient), surgical management (indications, risk, optimization for endometriosis, and uterine fibroids) and more. What about the need to understand adolescent health, endocrinology and reproduction for the purposes of fertility preservation in young patients with cancer? Training is a time to be exposed to the depth and breadth of our specialty. This foundational training will provide a practicing REI with the skills to make complex decisions, ask the right questions and give the best care, even if their ultimate practice becomes more focused. And optimization of training will also provide the foundation for those members of our specialty who will continue to move the field forward, to make the major advances that will improve health for women, men, and children.doesn't sound narrow to us. Drs. Barnhart and DeCherney suggest that the advent of IVF as, ‘‘the ultimate treatment to address all types of infertility,’’ has decreased the use of surgical approaches and has weakened our subspecialty, removing REIs from the ranks of gynecologists. While it is true that many who practice ‘‘IVF’’ often elect to refer their surgical patients, this does not mean that as a specialty, we have given or should give up our gynecologic practice to others. One must underscore that there is a difference between the experts who elect to specialize in IVF and others who continue to practice the art of reproductive medicine. REIs are experts in reproductive endocrinology, family planning, adolescent medicine, and minimally invasive surgery. Indeed, the development of IVF is but an example of how expertise and insight into the
VOL. 104 NO. 1 / JULY 2015
reproductive processes—both basic physiology and understanding the subtleties of follicular developments—has led to the very optimization of this treatment modality. This could not have happened without the melding of expert reproductive endocrinologists and superb surgeons. One cannot divorce the subtle endocrine events of follicular developments from follicular growth observed on ultrasound. Indeed, the best IVF practice requires profound understanding of menstrual cycle dynamics, which may not be appreciated by those not involved in our specialty. Irrespective of workforce and practice surveys, forward-thinking reproductive endocrine leaders must foster innovations and training in endocrinology, reproductive surgery, embryology, reproductive biology, and genetics.
Marcelle I. Cedars, M.D.a Zev Rosenwaks, M.D.b a Department of Obstetrics, Gynecology and Reproductive Sciences, University of California—San Francisco, San Francisco, California; and b The Ronald O. Perelman & Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, New York http://dx.doi.org/10.1016/j.fertnstert.2015.05.034 You can discuss this article with its authors and with other ASRM members at http://fertstertforum.com/cedarsm-subspecialist-reigynecology/ 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.
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