Embryo transfer by reproductive endocrinology fellows vs attending physicians: are live birth rates comparable?

Embryo transfer success: It is in our hands

Embryo transfer (ET) is considered as a critical step in the process of in vitro fertilization. Interestingly, studies have consistently shown significant outcome differences between physicians. Although the outcome of ET is not related to the physician's experience and specifically not different between fellows and attending physicians, certain techniques have been found to affect the success rate. This review summarizes the existing evidence regarding the impact of the individual physician performing ET and the techniques used.

Training for the future

PURPOSE OF REVIEW

The aim of this study was to review the evolving field of Reproductive Endocrinology and Infertility (REI) and describe the current and future challenges REI fellowship programmes in the United States are facing.

RECENT FINDINGS

The field of REI continues to rapidly evolve largely due to the tremendous advances within the assisted reproductive technologies (ARTs). Alongside this evolution, there is a lessening emphasis on graduates being proficient in all aspects of REI. Ongoing revisions to the REI fellowship structure reflect these changes in technology and contemporary practice patterns.

SUMMARY

REI is a rapidly evolving field and fellowship training is continually adapting to meet the changing landscape of our field.

Outcomes of embryo transfers performed by Reproductive Endocrinology and Infertility fellows vs. faculty: an 11-year retrospective review

OBJECTIVE

To compare the clinical pregnancy rate (CPR) and live birth rate (LBR) of embryo transfer episodes (ETEs) performed by Reproductive Endocrinology and Infertility fellows vs. those of ETEs performed by faculty physicians.

DESIGN

Retrospective cohort analysis.

SETTING

Academic reproductive endocrinology and infertility practice.

PATIENT(S)

In total, 3,073 ETEs for 1,488 unique patients were performed by fellows or faculty physicians between January 2009 and January 2020.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate and LBR.

RESULT(S)

Fifteen fellows performed 1,225 (39.9%) of 3,073 ETEs after completing 30 mock transfers. On comparing outcomes among fellowship years (FY1, FY2, and FY3), CPR (44.1% vs. 43.2% vs. 45.7%, respectively, P = .83) and LBR (39.1% vs. 38.1% vs. 38.4%, respectively, P = .97) were not significantly different. Fellowship year 1 fellows' initial 30 ETEs vs. all the remaining FY1 ETEs had a significantly higher CPR (48.1% vs. 40.5%, respectively, P = .030) and LBR (45.4% vs. 34.3%, respectively, P = .001). There were no significant differences between faculty versus fellow ETEs in terms of CPR (43.0% vs. 45.0%, respectively, P = .30) or LBR (37.3% vs. 39.8%, respectively, P = .16), even after adjusting for patient age, body mass index, primary infertility diagnosis, autologous vs. donor oocyte, fresh vs. frozen embryo, number of embryos transferred, type of transfer catheter, and year of transfer (P = .32 for CPR, P = .22 for LBR).

CONCLUSION(S)

Appropriately trained FY1 fellows had success rates maintained throughout all FYs. There were no significant differences in clinical outcomes between fellow- and faculty-performed transfers. These data demonstrated that allowing fellows to perform live embryo transfers is not detrimental to clinical outcomes.

Public reporting of IVF outcomes influences medical decision-making and physician training

Background

Since 1992 ART clinics have been required to report outcome data. Our objective was to assess practitioners’ opinions of the impact of public reporting of assisted reproductive technology (ART) outcomes on treatment strategies, medical decision-making, and fellow training.

Methods

Survey study performed in an academic medical center. Members of the Society of Reproductive Endocrinology and Infertility and the Society of Reproductive Surgery were recruited to participate in an online survey in April 2012.: Categorical survey responses were expressed as percentages. Written responses were categorized according to common themes regarding effects of reporting on participants’ medical management of patients. The study was primarily qualitative and was not powered to make statistical conclusions.

Results

Of 1019 surveys sent, 323 participants (31.7%) responded from around the United States, and 275 provided complete data. Nearly all (273 of 282; 96.8%) participants responded that public reporting sometimes or always affected other providers’ practices, and 264 of 281 (93.9%) responded that other practitioners were motivated to deny care to poor-prognosis patients to improve reported success rates. However, only 121 of 282 (42.9%) indicated that public reporting influenced their own medical management. The majority of respondents agreed that public reporting may hinder adoption of single embryo transfer practices (194 of 299; 64.9%) and contribute to the persistent rate of twinning in in vitro fertilization (187 of 279; 67%). A small majority (153 of 279; 54.8%) felt that public reporting did not benefit fellow training, and 58 (61.7%) of the 94 participants who trained fellows believed that having fellows perform embryo transfers reduced pregnancy rates. A small majority (163 of 277; 58.8%) of respondents reported their ART success rates on clinical websites. However, the majority (200 of 275; 72.7%) of respondents compared their success rates with those of other clinics. Finally, most respondents (211 of 277; 76%) believed that most centers that advertised their success rates did so in ways that were misleading to patients.

Conclusions

Public reporting of ART clinical outcomes is intended to drive improvement, promote trust between patients and providers, and inform consumers and payers. However, providers reported that they modified their practices, felt others denied care to poor-prognosis patients, and limited participation of trainees in procedures in response to public reporting of ART outcomes.

Do trained reproductive endocrinologists perform better than their trainees? Comparing clinical pregnancy rates and live birth rates after transfer of single fresh blastocysts

PURPOSE

To compare clinical pregnancy rates and live birth rates of single blastocyst transfers performed by attending physicians or fellows in reproductive endocrinology and infertility program.

METHODS

Retrospective study in an academic reproductive center. We evaluated 932 fresh single blastocyst transfer cycles performed by fellows in training (389 embryo transfers) and by attending physicians (543 embryo transfers).

RESULTS

There were no differences in the baseline characteristics and IVF cycle parameters between patients who had transfers performed by fellows or attending physicians. Transfers performed by attending physicians or fellows resulted in similar CPR (46.5 vs. 42.9%, p = 0.28) and LBR (38.3 vs. 34.2%, p = 0.11). Multivariate logistic regression analysis showed that even after adjusting for possible confounders (age, gravity, parity, baseline FSH, antral follicle count, dose of gonadotropins, stimulation protocol, and quality of embryo transferred), CPR (OR 0.81, CI 0.62-1.07) and LBR (OR 0.79, CI 0.6-1.05) in the two groups were comparable.

CONCLUSION

Clinical pregnancy rate and live birth rate after embryo transfer performed by attending staffs or fellows are comparable. This finding reassures fellowship programs that allowing fellows to perform embryo transfers does not compromise the outcome.

Impact of a prior cesarean delivery on embryo transfer: a prospective study

OBJECTIVE

To determine whether a history of prior cesarean delivery (CD) makes ET more difficult and impacts pregnancy outcomes.

DESIGN

Prospective cohort study.

SETTING

Tertiary care military facility.

PATIENT(S)

One hundred ninety-four patients with previous delivery undergoing IVF/intracytoplasmic sperm injection (ICSI)-ET.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Live birth (primary), positive hCG, clinical pregnancy, and time to perform ET.

RESULT(S)

There was no statistically significant difference between patients with a history of only vaginal deliveries versus those with a history of CD for live birth (39% vs. 32%), positive hCG (56% vs. 53%), or clinical pregnancy (49% vs. 41%). Embryo transfers took longer in the history of CD group (157 vs. 187 seconds) and were more likely to have mucus (27% vs. 45%) or blood (8% vs. 21%) on the catheter.

CONCLUSION(S)

Embryo transfers performed on patients with a prior CD took 30 seconds longer. They were also more likely to have blood or mucus on the catheter. Despite the apparently more difficult transfers, pregnancy outcomes were not different between the two groups.