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

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.

Analyzing the learning curve of vaginal pelvic reconstruction surgery with and without mesh by the cumulative summation test (CUSUM)

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.

The human factor: does the operator performing the embryo transfer significantly impact the cycle outcome?

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.

Assessment of operator performance during oocyte retrievals: residents' learning curve and continuous monitoring of senior physicians

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.

Non-invasive mitochondrial DNA quantification on Day 3 predicts blastocyst development: a prospective, blinded, multi-centric study

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.

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

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.

Learning Curve for Percutaneous Endoscopic Lumbar Diskectomy in Bi-needle Technique Using Cumulative Summation Test for Learning Curve

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.

Learning Curve of C-Arm Cone-beam Computed Tomography Virtual Navigation-Guided Percutaneous Transthoracic Needle Biopsy

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.

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.

Training Performance in Diagnosis of Congenital Uterine Anomalies With 3-Dimensional Sonography: A Learning Curve Cumulative Summation Analysis

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.

Are we ready to inject? Individualized LC-CUSUM training in ICSI

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.

Ultrasound guidance during embryo transfer: a systematic review and meta-analysis of randomized controlled trials

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.

Reporting of embryo transfer methods in IVF research: a cross-sectional study

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.

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

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.

The knee arthroscopy learning curve: quantitative assessment of surgical skills

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.

Individualized embryo transfer training: timing and performance

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.

Proficiency in oocyte retrieval assessed by the learning curve cumulative summation test

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.

Robotic sacrocolpopexy performance and cumulative summation analysis

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.

Student attainment of proficiency in a clinical skill: the assessment of individual learning curves

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.

Learning curve analysis of robot-assisted radical hysterectomy for cervical cancer: initial experience at a single institution

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.

Proficiency in oocyte retrieval: how many procedures are necessary for training?

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.

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

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.