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Moldenhauer JS, Johnson A, Van Mieghem T. International Society for Prenatal Diagnosis 2022 DEBATE: There should be formal accreditation and ongoing quality assurance/review for units offering fetal therapy that includes public reporting of outcomes. Prenat Diagn 2022; 43:411-420. [PMID: 36522853 DOI: 10.1002/pd.6286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/07/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022]
Abstract
The field of fetal therapy has so far escaped from formal accreditation and quality control. Despite that, current published evidence shows that outcomes of interventions in younger fetal therapy centers are similar to what is achieved in more experienced centers and outcomes of interventions have improved over time. The question however remains what is not being published and what should be the standard of care, given the lack of level 1 evidence from randomized controlled trials for many interventions. Formal collaborative networks such as NAFTnet and others allow for anonymized benchmarking of center outcomes, without publicly shaming (and financially punishing) underperforming centers. Large registries also allow for tracking of rare complications and may result in improved patient outcomes over time. Core outcome sets, which could serve as a basis for outcome reporting, are available for some conditions, but certainly not for all, resulting in communication difficulties between centers. Formal accreditation, quality control, and outcome reporting are hard to implement, expensive, and may result in decreasing access to care by pushing smaller centers out of the market. Despite the existing difficulties, international societies have committed to quality improvement, and fetal therapy programs are strongly recommended to participate in voluntary outcome tracking.
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Affiliation(s)
| | - Anthony Johnson
- The Fetal Center Department of Obstetrics and Gynecology and Reproductive Sciences Division of Fetal Intervention McGovern Medical School at The University of Texas Health Science Center Houston Texas USA
| | - Tim Van Mieghem
- Department of Obstetrics and Gynaecology Fetal Medicine Unit and Ontario Fetal Centre Mount Sinai Hospital and University of Toronto Toronto Ontario Canada
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Wu CJ, Huang KJ, Chang WC, Li YX, Wei LH, Sheu BC. Analyzing the learning curve of vaginal pelvic reconstruction surgery with and without mesh by the cumulative summation test (CUSUM). Sci Rep 2022; 12:7025. [PMID: 35488055 PMCID: PMC9054794 DOI: 10.1038/s41598-022-11039-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 04/18/2022] [Indexed: 11/29/2022] Open
Abstract
Women who underwent vaginal pelvic reconstructive surgery with or without mesh consecutively between 2004 and 2018 were retrospectively analyzed to determine the learning curve in vaginal pelvic reconstructive surgery. With cumulative summation (CUSUM) analysis of surgical failure and operation time, we assessed the learning curve of vaginal pelvic reconstructive surgery, including sacrospinous ligament fixation, anterior colporrhaphy, posterior colporrhaphy, and optional vaginal hysterectomy with or without mesh placement. The study is based on two individual surgeons who performed vaginal pelvic reconstructive surgery with or without mesh. Two hundred and sixty-four women with stage III or IV pelvic organ prolapse underwent vaginal pelvic reconstructive surgery by surgeons A or B. The median follow-up time of 44 months ranged from 24 to 120 months. Surgical proficiency was achieved in 32–33 vaginal pelvic reconstructive surgery procedures without mesh and 37–47 procedures in the same surgery with mesh. The total surgical success rates for surgeons A and B were 82.2% and 94.1%, with median follow-up times of 60 and 33 months, respectively. More procedures were needed for the learning curve of vaginal pelvic reconstructive surgery with mesh. Having crossed the proficiency boundary, the surgical success rate and operation time were improved.
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Affiliation(s)
- Chin-Jui Wu
- Department of Obstetrics and Gynecology, National Taiwan University Hospital , Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Kuan-Ju Huang
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, College of Medicine, National Taiwan University, 15F, No. 8, Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Wen-Chun Chang
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, College of Medicine, National Taiwan University, 15F, No. 8, Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Ying-Xuan Li
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, College of Medicine, National Taiwan University, 15F, No. 8, Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Lin-Hung Wei
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, College of Medicine, National Taiwan University, 15F, No. 8, Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Bor-Ching Sheu
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, College of Medicine, National Taiwan University, 15F, No. 8, Chung-Shan South Road, Taipei, 10002, Taiwan.
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Cirillo F, Patrizio P, Baccini M, Morenghi E, Ronchetti C, Cafaro L, Zannoni E, Baggiani A, Levi-Setti PE. The human factor: does the operator performing the embryo transfer significantly impact the cycle outcome? Hum Reprod 2021; 35:275-282. [PMID: 32100020 PMCID: PMC7048715 DOI: 10.1093/humrep/dez290] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/02/2019] [Indexed: 11/17/2022] Open
Abstract
STUDY QUESTION Is Ongoing Pregnancy Rate (OPR) operator-dependent, and can experience improve embryo transfer efficiency? SUMMARY ANSWER OPR is influenced by the operators who perform the embryo transfer (ET), and experience does not assure proficiency for everyone. WHAT IS KNOWN ALREADY ET remains the critical step in assisted reproduction. Although many other factors such as embryo quality and uterine receptivity impact embryo implantation, the proper ET technique is clearly an operator-dependent variable and as such it should be objectively standardized. STUDY DESIGN, SIZE, DURATION Retrospective comparative analysis including all fresh ETs performed between January 1996 and December 2016 at the Humanitas Fertility Center after IVF—ICSI cycles. PARTICIPANTS/MATERIALS, SETTING, METHODS IVF/ICSI fresh ETs performed by 32 operators, 19 824 cycles in all, were analyzed. All transfers consisting of freehand insertion of a preloaded soft catheter into the uterine cavity under transabdominal ultrasound guidance were considered. Two different statistical analyses were performed. First, a logistic regression model with a random intercept for the operator was used to estimate the heterogeneity of the rate of success among operators, accounting for woman age, FSH, number of oocytes retrieved, fertilization rate, year of the procedure, number and stage of transferred embryos and operator’s experience. Second, the relationship between experience and pregnancy rate was estimated separately for each operator by logistic regression, and operator-specific results were combined and compared in a random-effects meta-analysis. In both analyses, the operator’s experience at time t was measured in terms of number of embryo transfers performed before t. MAIN RESULTS AND THE ROLE OF CHANCE The heterogeneity among operators was highly significant (P value <0.001) and explained 44.5% of the total variability. The odds ratio of success of the worst operator in respect to the mean was equal to 0.84. For the best operator, the odds ratio of success was equal to 1.13 in respect to the mean. Based on the meta-analysis of the relationship between operator’s experience and success rate, it resulted that, on average, the operators’ performance did not improve with additional transfers. LIMITATIONS, REASONS FOR CAUTION At our center, operators become independent for ET’s after performing between 30 and 50 transfers under supervision. It is also possible that other relevant factors, such as embryologists on duty for the ET, have not been included in the present analysis and this may represent a potential bias. Among these, it should be mentioned that the embryologists on duty for the ET were not taken into consideration. WIDER IMPLICATIONS OF THE FINDINGS Continued performance analysis and the use of a digital simulator could help operators to test their expertise over time and either correct poor performance or avoid doing transfers. STUDY FUNDING/COMPETING INTEREST(S) None. TRIAL REGISTRATION NUMBER NCT03561129.
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Affiliation(s)
- F Cirillo
- Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, Humanitas Clinical and Research Center, IRCCS, via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - P Patrizio
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CO 06520, USA
| | - M Baccini
- Department of Statistics, Computer Science, Applications, University of Florence, 50134 Florence, Italic
| | - E Morenghi
- Biostatistics Unit, Humanitas Clinical and Research Center, IRCCS, via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - C Ronchetti
- Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, Humanitas Clinical and Research Center, IRCCS, via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - L Cafaro
- Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, Humanitas Clinical and Research Center, IRCCS, via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - E Zannoni
- Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, Humanitas Clinical and Research Center, IRCCS, via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - A Baggiani
- Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, Humanitas Clinical and Research Center, IRCCS, via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - P E Levi-Setti
- Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, Humanitas Clinical and Research Center, IRCCS, via Manzoni 56, Rozzano, 20089 Milan, Italy
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Verhaeghe C, El Hachem H, Inchboard L, Corroenne R, Dreux C, Jeanneteau P, Legendre G, Descamps P, Saulnier P, May-Panloup P, Bouet PE. Assessment of operator performance during oocyte retrievals: residents' learning curve and continuous monitoring of senior physicians. BMC MEDICAL EDUCATION 2021; 21:193. [PMID: 33823830 PMCID: PMC8025573 DOI: 10.1186/s12909-021-02615-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 03/11/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND The learning curve cumulative summation test (LC CUSUM test) allows to define an individualized learning curve and determine the moment when clinical proficiency is attained. After acquisition of the skills, the cumulative summation test (CUSUM test) allows to monitor the maintenance of the required level over time. The LC CUSUM test has been frequently used in the field of Obstetrics and Gynecology (Ob/Gyn) for several procedures, but only once for OR. METHODS We performed a retrospective study at Angers university hospital between May 2017 and September 2018. Seven Ob/Gyn residents and 5 senior physicians were included, and all OR performed during that time (n = 690) were analyzed. The performance index assessed was the oocyte retrieval rate (ORR), defined as the ratio of oocytes retrieved to follicles aspirated. We used the LC CUSUM test to analyze the learning curves of residents, and the CUSUM test to monitor the performance of senior physicians. An ORR ≥50% in 60% of retrievals was defined as the threshold for clinical proficiency. RESULTS Six hundred seventy-four oocyte retrieval (OR) were included: 315 were performed by residents, 220 by senior physicians, and 139 by both residents and physicians (mixed retrievals). Four residents (57%) reached the threshold after aspirating 82, 67, 53 and 46 ovaries, respectively. The mean number of ovaries aspirated in order to reach clinical proficiency was 62, and the mean number of weeks needed was 21. The duration of the learning period varied between 26 and 80 days. Two senior physicians (40%) remained proficient across the duration of the study, while two physicians (40%) had one statistically "suboptimal" OR, and one physician (20%) had two suboptimal retrievals. CONCLUSION There is a large variability in the duration of the learning period and the number of procedures needed for a resident to master OR. Senior physicians maintain an adequate performance.
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Affiliation(s)
- C Verhaeghe
- Department of Reproductive Medicine, Angers University Hospital, 49000, Angers, France.
| | - H El Hachem
- Department of Reproductive Medicine, Clemenceau Medical Center, Beirut, Lebanon
| | - L Inchboard
- Clinical Research Center, Angers University Hospital, Angers, France
| | - R Corroenne
- Department of Reproductive Medicine, Angers University Hospital, 49000, Angers, France
| | - C Dreux
- Department of Reproductive Medicine, Angers University Hospital, 49000, Angers, France
| | - P Jeanneteau
- Department of Reproductive Medicine, Angers University Hospital, 49000, Angers, France
| | - G Legendre
- Department of Reproductive Medicine, Angers University Hospital, 49000, Angers, France
| | - P Descamps
- Department of Reproductive Medicine, Angers University Hospital, 49000, Angers, France
| | - P Saulnier
- Clinical Research Center, Angers University Hospital, Angers, France
| | - P May-Panloup
- Department of Reproductive Medicine, Angers University Hospital, 49000, Angers, France
| | - P E Bouet
- Department of Reproductive Medicine, Angers University Hospital, 49000, Angers, France
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Stigliani S, Orlando G, Massarotti C, Casciano I, Bovis F, Anserini P, Ubaldi FM, Remorgida V, Rienzi L, Scaruffi P. Non-invasive mitochondrial DNA quantification on Day 3 predicts blastocyst development: a prospective, blinded, multi-centric study. Mol Hum Reprod 2020; 25:527-537. [PMID: 31174207 DOI: 10.1093/molehr/gaz032] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 04/19/2019] [Indexed: 12/28/2022] Open
Abstract
In ART, embryo quality evaluation is routinely based on morphological criteria. We previously demonstrated that the mitochondrial DNA (mtDNA)/genomic DNA (gDNA) ratio in culture medium was significantly associated with embryo quality and viability potential. The purpose of this prospective, blinded, multi-centric study was to validate the use of mtDNA/gDNA ratio in Day 3 spent medium as a predictor of human embryo developmental competence. The mtDNA/gDNA ratio was assessed in Day 3 culture media (n=484) of embryos from 143 patients by quantitative PCR. A mixed effect logistic regression model was applied. We found that mtDNA/gDNA ratio in Day 3 culture medium combined with embryo morphology improves the prediction upon blastulation compared to morphology alone (P < 0.0001), independent of patient and cycle characteristics. With regard to routine use in clinics, we evaluated the ability of the novel, combined grading score to improve selection of developmentally competent embryos of a single cohort. Including embryos from 44 patients, the sensibility and specificity of the scoring system based on Day 3 morphological stage were 92% and 13%, respectively. Integration with the culture medium mtDNA/gDNA ratio increased the performance of the method (sensibility: 95%; specificity: 65%). The results of this study suggest the possibility of carrying out a non-invasive evaluation of embryonic mtDNA content through the culture medium. When combined with embryo morphology, it has the potential to help embryologists rank embryos and choose which embryo(s) has the greater development potential, and thus should be transferred on Day 3, among sibling embryos with the same morphological grade.
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Affiliation(s)
- Sara Stigliani
- UOS Physiopathology of Human Reproduction, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | | | - Claudia Massarotti
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Academic Unit of Obstetrics and Gynecology, University of Genova, Genova, Italy
| | - Ida Casciano
- UOS Physiopathology of Human Reproduction, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Francesca Bovis
- Department of Health Sciences (DISSAL), University of Genova, Genova, Italy
| | - Paola Anserini
- UOS Physiopathology of Human Reproduction, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | | | - Valentino Remorgida
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Academic Unit of Obstetrics and Gynecology, University of Genova, Genova, Italy
| | - Laura Rienzi
- GENERA, Reproductive Medicine Center, Roma, Italy
| | - Paola Scaruffi
- UOS Physiopathology of Human Reproduction, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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Phithakwatchara N, Nawapun K, Viboonchart S, Jaingam S, Wataganara T. Simulation‐based fetal shunting training. Prenat Diagn 2019; 39:1291-1297. [DOI: 10.1002/pd.5599] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 10/18/2019] [Accepted: 10/19/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Nisarat Phithakwatchara
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyFaculty of Medicine Siriraj Hospital Bangkok Thailand
| | - Katika Nawapun
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyFaculty of Medicine Siriraj Hospital Bangkok Thailand
| | - Sommai Viboonchart
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyFaculty of Medicine Siriraj Hospital Bangkok Thailand
| | - Suparat Jaingam
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyFaculty of Medicine Siriraj Hospital Bangkok Thailand
| | - Tuangsit Wataganara
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyFaculty of Medicine Siriraj Hospital Bangkok Thailand
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Ding D, Jiang H, Nie J, Liu X, Guo SW. Concurrent Learning Curves of 3-Dimensional and Robotic-Assisted Laparoscopic Radical Hysterectomy for Early-Stage Cervical Cancer Using 2-Dimensional Laparoscopic Radical Hysterectomy as a Benchmark: A Single Surgeon's Experience. Med Sci Monit 2019; 25:5903-5919. [PMID: 31392971 PMCID: PMC6698092 DOI: 10.12659/msm.914952] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background For early-stage cervical cancers, radical hysterectomy (RH) with pelvic lymphadenectomy has been the standard care. This study compared the learning curves and intra-, peri-, and post-operative outcomes for 3-dimensional laparoscopic RH (3D-LRH) and robotic-assisted (RA)-LRH by a surgeon highly skilled in 2-dimensional (2D)-LRH for treatment of early-stage cervical cancer. Material/Methods Two hundred and thirty-nine patients with early-stage cervical cancer (FIGO stage: Ia2–IIa2) admitted to Shanghai Obstetrics and Gynecology Hospital, Fudan University were recruited into this prospective study: 54, 85, and 100 patients underwent 2D-, 3D-, and RA-LRH, respectively and were followed up. Patients’ demographic, clinical, and operative information was retrieved and compared. CUSUM (cumulative summation) analysis using a benchmark derived from previously performed 2D-LRHs. Results Both 3D- and RA-LRH had a steep learning curve. 3D-LRH was superior to 2D- and RA-LRH in terms of significantly shorter operating time. For all approaches, the operating time was associated with the uterus size of the patient and was not affected by other parameters. All approaches of LRH yielded comparable radicality and operative results other than operative time. Conclusions Both 3D- and RA-LRH approaches had similar radicality, and intra-operative and post-operative complication rates, however, 3D-LRH had the shortest operating time and lowest amount of blood loss. After reaching proficiency, RA-LRH had comparable operating time with that of 2D-LRH, and might be even shorter in cases where surgeon has acquired more experience. In countries where labor costs are low; 3D-LRH might be preferable to 2D- and RA-LRH for early-stage cervical cancer.
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Affiliation(s)
- Ding Ding
- Department of Gynecology, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China (mainland)
| | - Hongyuan Jiang
- Department of Gynecology, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China (mainland)
| | - Jichan Nie
- Department of Gynecology, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China (mainland)
| | - Xishi Liu
- Department of Gynecology, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China (mainland).,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, China (mainland)
| | - Sun-Wei Guo
- Department of Gynecology, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China (mainland).,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, China (mainland)
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Sun B, Shi C, Xu Z, Wu H, Zhang Y, Chen Y, Wu XD, Yuan W. Learning Curve for Percutaneous Endoscopic Lumbar Diskectomy in Bi-needle Technique Using Cumulative Summation Test for Learning Curve. World Neurosurg 2019; 129:e586-e593. [PMID: 31158541 DOI: 10.1016/j.wneu.2019.05.227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/26/2019] [Accepted: 05/27/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND The purpose of this study was to determine the number of cases needed to achieve the level of competence for percutaneous endoscopic lumbar diskectomy (PELD) via the bi-needle technique using the cumulative summation test for learning curve (LC-CUSUM). METHODS A retrospective design was used. We included 60 patients who underwent a single-level PELD via the bi-needle technique performed by a single surgeon. The surgeon had 5 years of experience in open surgery including the transforaminal endoscopic spine system and Yeung endoscopic spine system but no experience in the bi-needle technique. Surgery success was defined as an operative time <60 minutes, and the acceptable procedure was completed within 3 times of C-arm fluoroscopies. The LC-CUSUM was used to analyze the data. RESULTS The average operative time for PELD via the bi-needle technique was 58.3 ± 12.4 minutes. The mean operative time was 65.7 ± 12.1 minutes in the early learning period (30 cases) and 51.0 ± 7.5 minutes in the late learning period (30 cases) (P < 0.05). On the basis of the evaluation indexes of the operative time and radioactive exposure, the LC-CUSUM signaled proficiency for the bi-needle technique at the 50th-54th operation. Seven cases of complications were observed during the whole learning process, with 6 in the early period and 1 in the late period (P < 0.05). CONCLUSIONS The novel bi-needle technique is safe and effective for PELD with appropriate patients, and the learning curve is acceptable. A substantial learning period (50-54 cases) is needed before a spine surgeon can master the bi-needle technique.
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Affiliation(s)
- Bin Sun
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Changgui Shi
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Zeng Xu
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Huiqiao Wu
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Ying Zhang
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Yu Chen
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Xiao-Dong Wu
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Wen Yuan
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai, China.
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9
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Ahn SY, Park CM, Yoon SH, Kim H, Goo JM. Learning Curve of C-Arm Cone-beam Computed Tomography Virtual Navigation-Guided Percutaneous Transthoracic Needle Biopsy. Korean J Radiol 2019; 20:844-853. [PMID: 30993935 PMCID: PMC6470078 DOI: 10.3348/kjr.2018.0555] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 01/11/2019] [Indexed: 11/24/2022] Open
Abstract
Objective To evaluate the learning curve for C-arm cone-beam computed tomography (CBCT) virtual navigation-guided percutaneous transthoracic needle biopsy (PTNB) and to determine the amount of experience needed to develop appropriate skills for this procedure using cumulative summation (CUSUM). Materials and Methods We retrospectively reviewed 2042 CBCT virtual navigation-guided PTNBs performed by 7 novice operators between March 2011 and December 2014. Learning curves for CBCT virtual navigation-guided PTNB with respect to its diagnostic performance and the occurrence of biopsy-related pneumothorax were analyzed using standard and risk-adjusted CUSUM (RA-CUSUM). Acceptable failure rates were determined as 0.06 for diagnostic failure and 0.25 for PTNB-related pneumothorax. Results Standard CUSUM indicated that 6 of the 7 operators achieved an acceptable diagnostic failure rate after a median of 105 PTNB procedures (95% confidence interval [CI], 14–240), and 6 of the operators achieved acceptable pneumothorax occurrence rate after a median of 79 PTNB procedures (95% CI, 27–155). RA-CUSUM showed that 93 (95% CI, 39–142) and 80 (95% CI, 38–127) PTNB procedures were required to achieve acceptable diagnostic performance and pneumothorax occurrence, respectively. Conclusion The novice operators' skills in performing CBCT virtual navigation-guided PTNBs improved with increasing experience over a wide range of learning periods.
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Affiliation(s)
- Su Yeon Ahn
- Department of Radiology, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul, Korea.,Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Chang Min Park
- Department of Radiology, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul, Korea.,Cancer Research Institute, Seoul National University, Seoul, Korea.
| | - Soon Ho Yoon
- Department of Radiology, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul, Korea.,Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Hyungjin Kim
- Department of Radiology, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul, Korea
| | - Jin Mo Goo
- Department of Radiology, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul, Korea.,Cancer Research Institute, Seoul National University, Seoul, Korea
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10
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Behbehani S, Hasson J, Polesello S, Son WY, Tulandi T, Buckett W. Do trained reproductive endocrinologists perform better than their trainees? Comparing clinical pregnancy rates and live birth rates after transfer of single fresh blastocysts. J Assist Reprod Genet 2018; 35:885-890. [PMID: 29423789 PMCID: PMC5984878 DOI: 10.1007/s10815-018-1127-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 01/23/2018] [Indexed: 01/13/2023] Open
Abstract
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.
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Affiliation(s)
- Sadikah Behbehani
- Department of Obstetrics and Gynecology, McGill University Reproductive Center, Montreal, QC, Canada.
- , Montréal, Canada.
| | - Joseph Hasson
- Department of Obstetrics and Gynecology, McGill University Reproductive Center, Montreal, QC, Canada
| | - Stefano Polesello
- Department of Obstetrics and Gynecology, McGill University Reproductive Center, Montreal, QC, Canada
| | - W Y Son
- Department of Obstetrics and Gynecology, McGill University Reproductive Center, Montreal, QC, Canada
| | - Togas Tulandi
- Department of Obstetrics and Gynecology, McGill University Reproductive Center, Montreal, QC, Canada
| | - William Buckett
- Department of Obstetrics and Gynecology, McGill University Reproductive Center, Montreal, QC, Canada
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Pascual MA, Alcazar JL, Graupera B, Rodriguez I, Guerriero S, Mallafre A, de Lorenzo C, Hereter L. Training Performance in Diagnosis of Congenital Uterine Anomalies With 3-Dimensional Sonography: A Learning Curve Cumulative Summation Analysis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:2589-2594. [PMID: 27872415 DOI: 10.7863/ultra.16.02003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 03/06/2016] [Accepted: 03/11/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES We evaluated learning curve cumulative summation (CUSUM) of 3-dimensional (3D) sonography for diagnosis of congenital uterine anomalies and the deviations of the level of trainees' performance at the control-stage CUSUM. METHODS First-year (R1), second-year (R2), and third-year (R3) residents in obstetrics and gynecology received a training program to learn how to analyze 3D sonographic volumes and to classify congenital uterine anomalies. Each trainee worked on 155 3D sonographic volumes from preselected patients. Their results were evaluated by learning curve CUSUM and standard CUSUM. The time for each volume analysis was calculated for the expert examiner and the trainees. RESULTS Trainees R1, R2, and R3 reached competence at the 85th, 58th, and 40th evaluations, respectively, with success rates of 80%, 81%, and 85%, and kept the process under control with error levels of less than 4.5% until the end of the test. The trainees significantly reduced the average time of the evaluation per volume (P < .001). CONCLUSIONS Learning curve CUSUM provided quantitative indicators of the learning evolution of 3D sonography for diagnosis of congenital uterine anomalies by obstetrics and gynecology residents. The training received by the residents was adequate for diagnosis of congenital uterine anomalies using 3D sonography.
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Affiliation(s)
- M Angela Pascual
- Department of Obstetrics, Gynecology, and Reproduction, Institut Universitari Dexeus, Barcelona, Spain
| | - Juan Luís Alcazar
- Department of Obstetrics and Gynaecology, Medical School, University of Navarra, Pamplona, Spain
| | - Betlem Graupera
- Department of Obstetrics, Gynecology, and Reproduction, Institut Universitari Dexeus, Barcelona, Spain
| | - Ignacio Rodriguez
- Department of Obstetrics, Gynecology, and Reproduction, Institut Universitari Dexeus, Barcelona, Spain
| | - Stefano Guerriero
- Department of Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy
| | - Anna Mallafre
- Department of Obstetrics, Gynecology, and Reproduction, Institut Universitari Dexeus, Barcelona, Spain
| | - Cristina de Lorenzo
- Department of Obstetrics, Gynecology, and Reproduction, Institut Universitari Dexeus, Barcelona, Spain
| | - Lourdes Hereter
- Department of Obstetrics, Gynecology, and Reproduction, Institut Universitari Dexeus, Barcelona, Spain
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Durban M, García D, Obradors A, Vernaeve V, Vassena R. Are we ready to inject? Individualized LC-CUSUM training in ICSI. J Assist Reprod Genet 2016; 33:1009-15. [PMID: 26979744 DOI: 10.1007/s10815-016-0686-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 02/25/2016] [Indexed: 01/10/2023] Open
Abstract
PURPOSE The objective of this prospective, single center study was to develop a personalized training scheme for intracytoplasmic sperm injection (ICSI) through the use of learning curve-cumulative summation (LC-CUSUM), which allows to tailor training to the trainee performance, and to validate it against the performance of experienced embryologists. METHODS Five trainees microinjected latex microspheres (LM) into vitro matured oocytes. A microinjection was considered successful when the oocyte did not lyse in the 24 h following the injection. RESULTS Each trainee became proficient at ICSI after a variable number of injections, ranging from 35 to 80. Trainees that achieved proficiency went on to perform ICSI with human gametes in a clinical setting with proficiency comparable to that of experienced embryologists. CONCLUSIONS We show that LC-CUSUM based personalized ICSI training is feasible and allows trainees to be as proficient as trained embryologists when treating actual patients.
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Affiliation(s)
- Mercè Durban
- Clinica EUGIN, Travessera de les Corts 322, 08029, Barcelona, Spain
| | - Désireé García
- Fundació EUGIN, Travessera de les Corts 314, 08029, Barcelona, Spain
| | - Albert Obradors
- Clinica EUGIN, Travessera de les Corts 322, 08029, Barcelona, Spain
| | - Valerie Vernaeve
- Clinica EUGIN, Travessera de les Corts 322, 08029, Barcelona, Spain
| | - Rita Vassena
- Clinica EUGIN, Travessera de les Corts 322, 08029, Barcelona, Spain.
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Lapse in embryo transfer training does not negatively affect clinical pregnancy rates for reproductive endocrinology and infertility fellows. Fertil Steril 2015; 103:728-33.e2. [DOI: 10.1016/j.fertnstert.2014.12.102] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 12/05/2014] [Accepted: 12/05/2014] [Indexed: 11/24/2022]
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Teixeira DM, Dassunção LA, Vieira CVR, Barbosa MAP, Coelho Neto MA, Nastri CO, Martins WP. Ultrasound guidance during embryo transfer: a systematic review and meta-analysis of randomized controlled trials. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:139-148. [PMID: 25052773 DOI: 10.1002/uog.14639] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 07/03/2014] [Accepted: 07/14/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To summarize the current evidence on the effect of using ultrasound (US) guidance during embryo transfer (ET). METHODS In this systematic review, we included randomized controlled trials examining the effect of the use of US guidance during ET; data from studies using the same catheter type in study arms were not pooled with the results from studies that used different catheter types. RESULTS Twenty-one studies were included in the quantitative analysis: 18 compared 'US guidance' with 'clinical touch', of which one was subsequently excluded from the quantitative meta-analysis owing to a lack of available data, three studies compared transvaginal US guidance with transabdominal US guidance, and one study compared 'hysterosonometry before ET' with US guidance. Comparison of the use of US guidance with clinical touch, in studies that used the same catheter type in the study arms, indicated a benefit of using US guidance during ET on the rates of live birth (relative risk (RR), 1.48 (95% CI, 1.16-1.87)), based on two studies involving 888 women with moderate-quality evidence, and on the rates of clinical pregnancy (RR, 1.32 (95% CI, 1.18-1.46)), based on 13 studies involving 3641 women with high-quality evidence. However, when comparing the use of US guidance with clinical touch in studies that used different catheter types, the results suggest that using US guidance during ET has no effect on the rates of reproductive outcome: live birth (RR, 0.99 (95% CI, 0.83-1.19)), based on one study involving 1649 women with moderate-quality evidence; clinical pregnancy (RR, 1.04 (95% CI, 0.89-1.21)), based on five studies involving 2949 women with moderate-quality evidence. The estimates for the rate of miscarriage and for the other identified comparisons were imprecise. CONCLUSIONS The available evidence suggests that there is a benefit of using US guidance during ET. However, both US-guided transfer and clinical touch should be considered acceptable, as the benefit of US is not large and should be balanced against the increased cost and need to change the catheter type. More studies are required before conclusions can be drawn regarding the effect of other techniques on reproductive outcome.
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Affiliation(s)
- D M Teixeira
- Department of Obstetrics and Gynecology, Ribeirao Preto Medical School, University of Sao Paulo (DGO-FMRP-USP), Ribeirao Preto, Brazil; Evangelical University Hospital of Curitiba, Curitiba, Brazil
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Gambadauro P, Navaratnarajah R. Reporting of embryo transfer methods in IVF research: a cross-sectional study. Reprod Biomed Online 2014; 30:137-43. [PMID: 25530033 DOI: 10.1016/j.rbmo.2014.10.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 10/23/2014] [Accepted: 10/23/2014] [Indexed: 11/24/2022]
Abstract
The reporting of embryo transfer methods in IVF research was assessed through a cross-sectional analysis of randomized controlled trials (RCTs) published between 2010 and 2011. A systematic search identified 325 abstracts; 122 RCTs were included in the study. Embryo transfer methods were described in 42 out of 122 articles (34%). Catheters (32/42 [76%]) or ultrasound guidance (31/42 [74%]) were most frequently mentioned. Performer 'blinding' (12%) or technique standardization (7%) were seldom reported. The description of embryo transfer methods was significantly more common in trials published by journals with lower impact factor (less than 3, 39.6%; 3 or greater, 21.5%; P = 0.037). Embryo transfer methods were reported more often in trials with pregnancy as the main end-point (33% versus 16%) or with positive outcomes (37.8% versus 25.0%), albeit not significantly. Multivariate logistic regression confirmed that RCTs published in higher impact factor journals are less likely to describe embryo transfer methods (OR 0.371; 95% CI 0.143 to 0.964). Registered trials, trials conducted in an academic setting, multi-centric studies or full-length articles were not positively associated with embryo transfer methods reporting rate. Recent reports of randomized IVF trials rarely describe embryo transfer methods. The under-reporting of research methods might compromise reproducibility and suitability for meta-analysis.
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Affiliation(s)
- Pietro Gambadauro
- Karolinska Institutet, LIME/NASP - C7, 17 177 Stockholm, Sweden; Res Medica Sweden, Gynaecology & Reproductive Medicine, 752 24 Uppsala, Sweden.
| | - Ramesan Navaratnarajah
- Bart's Health NHS Trust, Obstetrics and Gynaecology, The Royal London Hospital, E1 1BB London, UK; Katherine Twining Network, Queen Mary University of London, E1 2AB London, UK
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Eaton JL, Zhang X, Barnes RB. Embryo transfer by reproductive endocrinology fellows vs attending physicians: are live birth rates comparable? Am J Obstet Gynecol 2014; 211:494.e1-5. [PMID: 24881830 DOI: 10.1016/j.ajog.2014.05.042] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 05/08/2014] [Accepted: 05/27/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare live birth rates following ultrasound-guided embryo transfer (ET) by reproductive endocrinology and infertility fellows versus attending physicians. STUDY DESIGN Women who underwent their first day-3, fresh, nondonor ET between Oct. 1, 2005, and April 1, 2011, at our academic center were included in this retrospective cohort study. Embryos were designated high quality if they had 8 cells, less than 10% fragmentation, and no asymmetry. ET was performed with the afterload technique under ultrasound guidance. Categorical variables were evaluated with the χ(2) test and continuous variables with the Student t test. Logistic regression was performed to assess the relationship between ET physician and live birth rate while adjusting for potential confounders. RESULTS Seven hundred sixty women underwent ET by an attending physician, and 104 by a fellow. Baseline characteristics were similar between the groups. The live birth rate was 31% following ET by an attending physician, compared with 34% following ET by a fellow (P = .65). Logistic regression adjusting for potential confounders demonstrated no significant association between ET physician and live birth rate. CONCLUSION This retrospective study demonstrated no significant difference in live birth rates following ultrasound-guided ET by fellows vs attending physicians at our institution. These data suggest that academic practices using the afterload method and ultrasound guidance can train fellows to perform ET without compromising success rates.
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Affiliation(s)
- Jennifer L Eaton
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University School of Medicine, Chicago, IL.
| | - Xingqi Zhang
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University School of Medicine, Chicago, IL
| | - Randall B Barnes
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University School of Medicine, Chicago, IL
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Piessens S, Healey M, Maher P, Tsaltas J, Rombauts L. Can anyone screen for deep infiltrating endometriosis with transvaginal ultrasound? Aust N Z J Obstet Gynaecol 2014; 54:462-8. [DOI: 10.1111/ajo.12242] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 06/26/2014] [Indexed: 01/01/2023]
Affiliation(s)
- Sofie Piessens
- Women's and Children's Program; Monash Health; Clayton Victoria Australia
| | - Martin Healey
- Department of Obstetrics and Gynaecology; University of Melbourne; Parkville Victoria Australia
- Department of Gynaecology; Royal Women's Hospital; Parkville Victoria Australia
| | - Peter Maher
- Department of Obstetrics and Gynaecology; University of Melbourne; Parkville Victoria Australia
- Department Gynaecology; Mercy Hospital for Women; Heidelberg Victoria Australia
| | - Jim Tsaltas
- Women's and Children's Program; Monash Health; Clayton Victoria Australia
| | - Luk Rombauts
- Women's and Children's Program; Monash Health; Clayton Victoria Australia
- Department of Obstetrics and Gynaecology; Monash University; Clayton Victoria Australia
- Monash IVF; Clayton Victoria Australia
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Dessolle L. Quality control of training and performance in embryo transfer: time to broadcast LC CUSUM and CUSUM tests. Hum Reprod 2014; 29:2353-4. [PMID: 25035433 DOI: 10.1093/humrep/deu181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lionel Dessolle
- CHU Brest, service de gynécologie obstétrique et médecine de la reproduction, Hôpital Morvan, Brest 29200, France
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Hodgins JL, Veillette C, Biau D, Sonnadara R. The knee arthroscopy learning curve: quantitative assessment of surgical skills. Arthroscopy 2014; 30:613-21. [PMID: 24725315 DOI: 10.1016/j.arthro.2014.02.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 02/09/2014] [Accepted: 02/13/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess orthopaedic trainees performing diagnostic knee arthroscopies and evaluate procedural competence using a novel statistical method, the Cumulative Summation Test for Learning Curve (LC-CUSUM). METHODS Twenty orthopaedic trainees in postgraduate year (PGY) 1 through 5 performed diagnostic knee arthroscopy and were evaluated intraoperatively with a validated 10-point knee task-specific checklist (TSCL) and 50-point global rating scale (GRS). A score of 40 points or greater (of 50 points) for the GRS and 8 points or greater (of 10 points) for the knee TSCL was considered to indicate a successful procedure. For the LC-CUSUM analysis, adequate performance was defined as a 10% failure rate, inadequate performance was defined as a 30% failure rate, and an acceptable deviation from adequate performance was defined as 10%. A limit h equal to 1.6 was selected to give a true-discovery rate of 90% and a false-discovery rate of 10% over 50 procedures. RESULTS A total of 340 consecutive procedures were performed by 20 trainees during the 12-month study period. The cumulative number of arthroscopic procedures performed by trainees before study start increased with increasing PGY. The median number of arthroscopic procedures performed per trainee was 16.5 (interquartile range, 14 to 21.75). Competency in knee arthroscopy for the TSCL was achieved by 8 trainees (40%), after a median of 16 procedures (interquartile range, 13 to 20), and for the GRS by only a single trainee (5%), after 14 procedures. Threshold-adjusted curves stratified by PGY level enabled multiple trainees to achieve competency for both the TSCL and GRS. CONCLUSIONS The LC-CUSUM can be successfully applied to knee arthroscopy to provide an individualized assessment of performance and quantitatively demonstrate competency for basic arthroscopic tasks. CLINICAL RELEVANCE The LC-CUSUM is an effective method to evaluate procedure competence in arthroscopic training and can provide objective feedback and benchmarks in the learning phase.
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Affiliation(s)
- Justin L Hodgins
- Department of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada.
| | | | - David Biau
- Département de Chirurgie Orthopédique, Hôpital Cochin, Paris, France
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López MJ, García D, Rodríguez A, Colodrón M, Vassena R, Vernaeve V. Individualized embryo transfer training: timing and performance. Hum Reprod 2014; 29:1432-7. [PMID: 24781427 DOI: 10.1093/humrep/deu080] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
STUDY QUESTION How long is the individualized training and the stability of competence for the embryo transfer (ET) technique? SUMMARY ANSWER The embryo transfer technique is easy-to-learn, hardly unlearned, and training should be individualized by monitoring with learning curve-cumulative summation (LC-CUSUM) curves. WHAT IS KNOWN ALREADY Like many medical procedures, embryo transfer is an operator-dependent technique. Individualized or standardized training of these medical procedures should be monitored to determine when competence is acquired. STUDY DESIGN, SIZE, DURATION This prospective, monocentric study involving five embryo transfer trainees was carried out between August 2011 and November 2012. PARTICIPANTS/MATERIALS, SETTING, METHODS The study was carried out in a large private clinic. Five gynaecologist trainees during their first year of assisted reproduction subspecialty performed embryo transfer for patients undergoing either fresh IVF, oocyte donor IVF, or frozen embryo transfer. There were 586 embryo transfers performed in 96 sessions of 3-10 embryo transfers each. An embryo transfer was considered successful if it gave rise to a positive pregnancy test 14 days later. LC-CUSUM and cumulative summation (CUSUM) curves were used to determine when competence was acquired and whether it was maintained over time, respectively. The length of time between two consecutive sessions was assessed for an effect on consolidation of the acquired competence. MAIN RESULTS AND THE ROLE OF CHANCE We observed that all five trainees became proficient in embryo transfer by procedure 15 (after procedure 15, 9, 7, 13 and 9, respectively). Once competence was achieved, one of the five trainees showed a loss of proficiency. After having acquired competence, the median pregnancy rate per embryo transfer session was significantly lower when the interval between consecutive embryo transfer sessions was ≥10 days compared with <10 days (20.0 versus 46.7%; P = 0.006). LIMITATIONS, REASONS FOR CAUTION The patient groups included in the study were heterogeneous (IVF, oocyte donor IVF and frozen embryo transfer) and their outcomes are very variable; thus the distribution and proportion of these groups can determine the timing of competence acquisition. Our data show that low numbers of embryo transfer are needed to acquire competence, but since a relative high percentage of embryo transfers in our practice are from oocyte donor IVF, extrapolation of the findings to other clinical context should be done with caution. WIDER IMPLICATIONS OF THE FINDINGS Personalized embryo transfer training is feasible and useful, allowing clinics, on one hand, to offer a maximum chances of pregnancy with fully trained personnel, and the other hand, to avoid the superfluous and costly overtraining of already proficient trainees. Furthermore, it is advisable to maintain a short interval of time between consecutive embryo transfer sessions after a trainee has acquired competence, to avoid a significant drop in the resulting pregnancy rate. STUDY FUNDING/COMPETING INTEREST(S) This work was supported in part by funding from Fundació Privada EUGIN. There are no conflicts of interest to declare.
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Dessolle L, Leperlier F, Biau DJ, Fréour T, Barrière P. Proficiency in oocyte retrieval assessed by the learning curve cumulative summation test. Reprod Biomed Online 2014; 29:187-92. [PMID: 24832373 DOI: 10.1016/j.rbmo.2014.03.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 03/13/2014] [Accepted: 03/19/2014] [Indexed: 11/26/2022]
Abstract
The number of procedures required for a trainee to reach proficiency in oocyte retrieval and the criteria applied to define performance are not well defined. To evaluate the learning curve of oocyte retrieval, this study prospectively evaluated three trainees over 6 months. Oocyte retrieval was monitored by the learning curve-cumulative summation test (LC-CUSUM), a specific statistical tool designed to indicate when a predefined level of performance is reached. Oocytes were retrieved from one ovary by the trainee and from the second ovary by a senior operator in a randomized manner. The main outcome measure was the ratio of oocytes collected and follicles aspirated. A trainee's ratio of ≥ 80% of the senior operator's defined success. From 17 to >50 procedures were necessary for the trainees to reach the predefined level of performance. Cumulative summation tests implemented after the learning phase confirmed that performance was maintained. The present study confirms the large variability in acquiring proficiency for surgical procedures. It provides an exportable model for a quantitative tailored monitoring of the learning curve and for continuous monitoring of performance in oocyte retrieval.
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Affiliation(s)
- Lionel Dessolle
- Service de Biologie et Médecine de la Reproduction, Centre Hospitalier Universitaire de Nantes, 38, Bd Jean Monnet, 44093 Nantes Cedex 1, France.
| | - Florence Leperlier
- Service de Biologie et Médecine de la Reproduction, Centre Hospitalier Universitaire de Nantes, 38, Bd Jean Monnet, 44093 Nantes Cedex 1, France
| | - David J Biau
- Département de Chirurgie Orthopédique, APHP - Hôpital Cochin, Université René Descartes, Paris, France
| | - Thomas Fréour
- Service de Biologie et Médecine de la Reproduction, Centre Hospitalier Universitaire de Nantes, 38, Bd Jean Monnet, 44093 Nantes Cedex 1, France
| | - Paul Barrière
- Service de Biologie et Médecine de la Reproduction, Centre Hospitalier Universitaire de Nantes, 38, Bd Jean Monnet, 44093 Nantes Cedex 1, France
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Abstract
OBJECTIVES This study aimed to apply Cumulative Summation (CUSUM) analysis as a tool to monitor robotic sacrocolpopexy (RSCP) proficiency over time. METHODS A retrospective analysis of all women who underwent RSCP between September of 2008 and December of 2011 at the University of North Carolina at Chapel Hill. The performance for 2 attending surgeons was analyzed sequentially over time. Intraoperative complications such as genitourinary or gastrointestinal tract injury, conversion to laparotomy, pulmonary embolus, hemorrhage, and blood transfusion, were identified by International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes. A successful outcome was defined as no intraoperative complications. The target value of success was set at less than 10% complications. CUSUM analysis was then sequentially applied to all RSCP cases for 2 attending surgeons. RESULTS Over 27 months, 169 RSCPs were performed. The first surgeon performed 107 RSCPs and the second surgeon performed 62 RSCPs with 8 (7.4%) and 3 (4.9%) intraoperative complications, respectively. Total complications included 7 (4.1%) cystotomies, 2 (1.2%) vaginal lacerations, 1 (0.6%) blood transfusion, and 1 (0.6%) bowel perforation. A CUSUM graph was created for each surgeon. CONCLUSIONS CUSUM analysis was successfully applied to monitor RSCP proficiency. Such testing of individual successive procedural outcomes with CUSUM may offer an objective tool to aid in physician self-assessment.
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Campbell RD, Hecker KG, Biau DJ, Pang DSJ. Student attainment of proficiency in a clinical skill: the assessment of individual learning curves. PLoS One 2014; 9:e88526. [PMID: 24586337 PMCID: PMC3930528 DOI: 10.1371/journal.pone.0088526] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 01/08/2014] [Indexed: 11/29/2022] Open
Abstract
The aims of this study were to determine if the learning curve cumulative summation test (LC-CUSUM) can differentiate proficiency in placing intravenous catheters by novice learners, and identify the cause of failure when it occurred. In a prospective, observational study design 6 undergraduate students with no previous experience of placing intravenous catheters received standardized training by a board certified veterinary anesthesiologist in intravenous catheter placement technique. Immediately following training, each student attempted 60 intravenous catheterizations in a dog mannequin thoracic limb model. Results were scored as a success or failure based upon completion of four specific criteria, and where catheter placement failure occurred, the cause was recorded according to pre-defined criteria. Initial acceptable and unacceptable failure rates were set by the study team and the LC-CUSUM was used to generate a learning curve for each student. Using 10% and 25% acceptable and unacceptable failure rates, 3 out of 6 students attained proficiency, requiring between 26 to 48 attempts. Applying 25% and 50% acceptable and unacceptable failure rates, 5 of 6 students obtained proficiency, requiring between 18 and 55 attempts. Wide inter-individual variability was observed and the majority of failed catheterisation attempts were limited to two of the four pre-defined criteria. These data indicate that the LC-CUSUM can be used to generate individual learning curves, inter-individual variability in catheter placement ability is wide, and that specific steps in catheter placement are responsible for the majority of failures. These findings may have profound implications for how we teach and assess technical skills.
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Affiliation(s)
- Robert D. Campbell
- Calgary Animal Referral and Emergency Centre, Calgary, Alberta and the Faculty of Veterinary Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kent G. Hecker
- Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David J. Biau
- Département de Biostatistique et Informatique Médicale, Hôpital Saint-Louis, AP-HP Paris, France
| | - Daniel S. J. Pang
- Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- * E-mail:
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Hynek M, Smetanová D, Stejskal D, Zvárová J. Exponentially weighted moving average chart as a suitable tool for nuchal translucency quality review. Prenat Diagn 2014; 34:367-76. [DOI: 10.1002/pd.4314] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 12/30/2013] [Accepted: 12/31/2013] [Indexed: 12/30/2022]
Affiliation(s)
- Martin Hynek
- Gennet, Centre for Fetal Medicine and Reproductive Genetics; Prague Czech Republic
- Institute of Hygiene and Epidemiology, First Faculty of Medicine; Charles University; Prague Czech Republic
- Department of Gynecology and Obstetrics; Thomayer Hospital; Prague Czech Republic
| | - Dagmar Smetanová
- Gennet, Centre for Fetal Medicine and Reproductive Genetics; Prague Czech Republic
| | - David Stejskal
- Gennet, Centre for Fetal Medicine and Reproductive Genetics; Prague Czech Republic
| | - Jana Zvárová
- European Centre for Medical Informatics, Statistics and Epidemiology; Institute of Computer Science AS CR; Prague Czech Republic
- Institute of Hygiene and Epidemiology, First Faculty of Medicine; Charles University; Prague Czech Republic
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Je S, Cho Y, Choi HJ, Kang B, Lim T, Kang H. An application of the learning curve–cumulative summation test to evaluate training for endotracheal intubation in emergency medicine. Emerg Med J 2013; 32:291-4. [DOI: 10.1136/emermed-2013-202470] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Yim GW, Kim SW, Nam EJ, Kim S, Kim YT. Learning curve analysis of robot-assisted radical hysterectomy for cervical cancer: initial experience at a single institution. J Gynecol Oncol 2013; 24:303-12. [PMID: 24167665 PMCID: PMC3805910 DOI: 10.3802/jgo.2013.24.4.303] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 07/17/2013] [Accepted: 07/18/2013] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the learning curve and perioperative outcomes of robot-assisted laparoscopic procedure for cervical cancer. METHODS A series of 65 cases of robot-assisted laparoscopic radical hysterectomies with bilateral pelvic lymph node dissection for early stage cervical cancer were included. Demographic data and various perioperative parameters including docking time, console time, and total operative time were reviewed from the prospectively collected database. Console time was set as a surrogate marker for surgical competency, in addition to surgical outcomes. The learning curve was evaluated using cumulative summation method. RESULTS The mean operative time was 190 minutes (range, 117 to 350 minutes). Two unique phases of the learning curve were derived using cumulative summation analysis; phase 1 (the initial learning curve of 28 cases), and phase 2 (the improvement phase of subsequent cases in which more challenging cases were managed). Docking and console times were significantly decreased after the first 28 cases compared with the latter cases (5 minutes vs. 4 minutes for docking time, 160 minutes vs. 134 minutes for console time; p<0.001 and p<0.001, respectively). There was a significant reduction in blood loss during operation (225 mL vs. 100 mL, p<0.001) and early postoperative complication rates (28% vs. 8.1%, p=0.003) in phase 2. No conversion to laparotomy occurred. CONCLUSION Improvement of surgical performance in robot-assisted surgery for cervical cancer can be achieved after 28 cases. The two phases identified by cumulative summation analysis showed significant reduction in operative time, blood loss, and complication rates in the latter phase of learning curve.
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Affiliation(s)
- Ga Won Yim
- Institute of Women's Life Medical Science, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea
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The Vestibular Schwannoma Surgery Learning Curve Mapped by the Cumulative Summation Test for Learning Curve. Otol Neurotol 2013; 34:1469-75. [DOI: 10.1097/mao.0b013e31829bfc54] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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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. [DOI: 10.1016/j.fertnstert.2013.03.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 03/07/2013] [Accepted: 03/14/2013] [Indexed: 10/27/2022]
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Proficiency in oocyte retrieval: how many procedures are necessary for training? Fertil Steril 2011; 96:e143; author reply e144. [DOI: 10.1016/j.fertnstert.2011.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Accepted: 06/07/2011] [Indexed: 10/18/2022]
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Reply of the Authors. Fertil Steril 2011. [DOI: 10.1016/j.fertnstert.2011.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Proficiency in oocyte retrieval: how many procedures are necessary for training? Fertil Steril 2011; 95:2279-82. [PMID: 21457969 DOI: 10.1016/j.fertnstert.2011.02.055] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Revised: 02/17/2011] [Accepted: 02/28/2011] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine a minimum number of procedures required for proficiency in oocyte retrieval and to characterize skill acquisition. DESIGN Retrospective analysis. SETTING Reproductive endocrinology and infertility fellowship training program. SUBJECT(S) Fellows in training from 2005 to 2007 and 2008 to 2010. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Proficiency scores were calculated by dividing the number of oocytes retrieved by oocytes expected. The 2005 to 2007 trainees were grouped and proficiency scores calculated as an average during specific points in their training. The 2008 to 2010 trainees were compared individually to determine differences in individual skill acquisition. RESULT(S) A greater number of oocytes were retrieved than expected, 8.6 versus 7.6. A relatively lower proficiency score was noted during the first 10 trainee aspirations (proficiency score=1.1) compared with subsequent aspirations (proficiency score=1.25 for retrievals 11-20, proficiency score=1.21 for retrievals 21-30 and >31). When individual fellows' scores were calculated, the majority achieved proficiency by 20 aspirations, and all but one trainee achieved the mean staff proficiency score by 50 retrievals. CONCLUSION(S) Regardless of a trainee's initial proficiency in oocyte retrieval, there were no statistically significant differences in the learning curve between trainees. The majority of individual fellows in training demonstrate proficiency in follicular aspirations within 20 procedures; however, a minority may require 50 procedures to achieve the proficiency of an attending physician.
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Use of the Learning Curve-Cumulative Summation test for quantitative and individualized assessment of competency of a surgical procedure in obstetrics and gynecology: fetoscopic laser ablation as a model. Am J Obstet Gynecol 2011; 204:218.e1-9. [PMID: 21111398 DOI: 10.1016/j.ajog.2010.10.910] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 10/08/2010] [Accepted: 10/13/2010] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We sought to determine the learning curve (LC) for fetoscopic laser photocoagulation (FLP) as a model for the evaluation of training in surgical procedures. STUDY DESIGN A retrospective review of consecutive case series of FLP from 2 centers with 3 operators (operator I [O-I], observer trained; operator II [O-II], hands-on trained; and operator III [O-III], clinical fellow) was performed and the LC-cumulative summation (CUSUM) test was plotted. RESULTS The acceptable and unacceptable success rates for at least 1 fetus survival after FLP were set at 82% and 70%, respectively, from a systematic review. A total of 171 consecutive cases were performed by the 3 operators (O-I, 91; O-II, 49; and O-III, 31). From LC-CUSUM test O-I needed 60 procedures, O-II needed 20 procedures, and O-III needed 20 procedures to reach an acceptable performance rate for at least 1 survivor. CONCLUSION The LC-CUSUM test can be used to accurately assess the LC in a surgical procedure in obstetrics and gynecology. Hands-on trained operators exhibit a shorter LC.
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Bazot M, Daraï E, Biau DJ, Ballester M, Dessolle L. Learning curve of transvaginal ultrasound for the diagnosis of endometriomas assessed by the cumulative summation test (LC-CUSUM). Fertil Steril 2011; 95:301-3. [DOI: 10.1016/j.fertnstert.2010.08.033] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2010] [Revised: 07/12/2010] [Accepted: 08/13/2010] [Indexed: 10/19/2022]
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Opinion : how should we define success in assisted reproduction? is live birth rate the gold standard measurement? J Assist Reprod Genet 2010; 27:691-3. [PMID: 20824322 DOI: 10.1007/s10815-010-9472-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Accepted: 08/17/2010] [Indexed: 10/19/2022] Open
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Improving of pregnancy rate by modifying embryo transfer technique. Fertil Steril 2010; 94:e68. [PMID: 20691436 DOI: 10.1016/j.fertnstert.2010.06.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Accepted: 06/28/2010] [Indexed: 11/22/2022]
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