Efficacy of intrauterine inseminations as a training modality for performing embryo transfer in reproductive endocrinology and infertility fellowship programs

Capsule:
Pregnancy rates for the first 100 ETs performed by reproductive endocrinology and infertility fellows were unchanged after an IUI training requirement. The substantial variation noted among fellows decreased as more ETs were completed.

Authors:
Divya K. Shah, M.D., Stacey A. Missmer, Sc.D., Katharine F.B. Correia, M.A., Catherine Racowsky, Ph.D., Elizabeth Ginsburg, M.D.

Volume 100, Issue 2, Pages 386-391, August 2013

Abstract:

Objective:
To assess pregnancy rates before and after a training intervention in which reproductive endocrinology and infertility fellows were required to perform 100 IUIs before performing ETs.

Design:
Retrospective cohort study.

Setting:
Large, academic training program.

Patient(s):
Not applicable.

Intervention(s):
Comparing pregnancy rates between two time periods: July 1998–June 2001 (before IUI intervention) and July 2001–June 2010 (after IUI intervention).

Main Outcome Measure(s):
Clinical pregnancy rate (PR) for the first 100 ETs performed by fellows before and after the IUI training; median attending physician PR during each time period served as the referent. Multivariate generalized estimating equations were used to calculate odds of pregnancy per ET for fellows as compared with attending physicians.

Result(s):
Multivariate analyses revealed no significant difference in PR for the first 100 ETs performed by fellows as compared with attending physicians, before or after the IUI training requirement (odds ratio 0.99, 95% confidence interval 0.82–1.20 and odds ratio 0.91, 95% confidence interval 0.81–1.30, respectively). The median attending physician PR in the preintervention group was exceeded by fellows after the first 70 ETs; fellows in the postintervention group exceeded the median attending physician PR after 100 ETs. The PR in both groups improved as fellows progressed from the first 20 to 100 ETs.

Conclusion(s):
The PR for the first 100 ETs performed by fellows was unchanged after implementing an IUI training requirement. The substantial variation noted among individual fellows decreased as more ETs were completed.

  • Lauren Johnson

    Thank you to the authors for a very interesting paper. Fellow training in ET is certainly an important issue that deserves further investigation. I am curious about the role of ultrasound guidance during the ET and during the IUI intervention. Were IUIs performed under ultrasound guidance? It would be interesting to see if use of ultrasound during the IUI intervention and during ET impacted the learning curve for fellows. I would hypothesize that ultrasound guidance would improve clinical pregnancy rates and shorten the learning curve, but I am curious about the authors’ perspectives on this question.

  • Amanda N. Kallen

    Thank you for an interesting and relevant paper especially for current fellows such as myself! I noticed that in both situations (pre- and post-IUI intervention), there was a drop in clinical pregnancy rates at about 40 ETs, and the numbers then started to rebound. Do the authors have any hypothesis as to why this might be so?

  • Micah Hill

    I appreciate your study evaluating embryo transfers performed by fellows, a common topic of discussion when fellows are together at various meetings. It was especially interesting to see the large variation in outcomes between fellows when experience was low and that the variation narrowed so markedly with increasing fellow experience. I was curious if your program planned on re-addressing the policy of requiring 100 IUIs prior to ET, given that the data showed no change in outcomes with this policy? Your data seems to suggest that increased experience and careful monitoring of success rates with additional training as indicated is a reasonable approach to fellow ET training.

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