Hello, everyone, and to our online global audience, welcome to another Fertility and Sterility Journal Club Global. I'm Micah Hill, the media editor for Fertility and Sterility, and we're here at one of our favorite journal clubs, our third annual faculty versus fellow debate, live from Park City, Utah, at the Society for Reproductive Endocrinology and Infertility Fellows Symposium. The fellows this year are putting their two-year winning streak on the line in what we hope is a great debate, and Pietro and I have flipped roles, and he will be hosting, so Pietro, over to you.
Thanks, Micah. Hi, everyone. My name is Pietro Bordoletto.
I'm a third-year fellow at Weill Cornell, and I also happen to be the FNS Reports media editor, as well as the Interactive Associate-in-Chief for Fertility and Sterility. I want to say hello to our live audience. We have over 100 REI and andrology fellows from all over the country, as well as a group of illustrious faculty, both on stage and in the audience, and hello to our virtual audience who's joining us as well.
Today, we're going to be discussing a pretty important topic to the folks here in the audience. Should fellows be performing live embryo transfers during training? I have my co-host in the audience who will be fielding questions, Dr. Micah Hill, who's the REI Fellowship Director at the NIH and media editor for FNS. On stage with me, I have some compatriots, I have some fellows.
I have Dr. Callum Potts, who's a third-year REI Fellow at the University of Vermont. Dr. Erica New, who's a third-year REI Fellow at the University of South Florida, as well as a Interactive Associate for Fertility and Sterility, and happens to be our SREI Associate Co-Chair. And then, finally, Dr. Sarah Bjorkman, who's a third-year Fellow at the University of Iowa and happens to have a very special interest in fellowship education and embryo transfers.
There's going to be a small twist today. In the interest of a healthy debate, we're actually going to have the fellows take the con side, arguing against fellows performing live embryo transfers in fellowship, with the understanding that they don't all necessarily agree with this opinion, but in the interest of healthy debate, I think it'll be fun. And arguing on behalf of the fellows for a change will be the faculty to my right.
Today, I'm joined by Dr. Erica Johnstone, who's the REI Fellowship Program Director at the University of Utah, and a member of the REI Division of AABOG. I have Dr. Kenan Omertag, who's the Associate Professor and Chief of the Division of REI at Wash U, and then Dr. Steve Young, who's faculty at the University of North Carolina. Today's actually a really interesting journal club, because we happen to have some data to support what we're going to be talking about, which is a little unusual in the field of reproductive medicine.
And today, the data's actually coming from one of our very own. Dr. Colleen Miller has graciously agreed to not only publish in Fertility and Sterility her work entitled, entitled, excuse me, Clinical Outcomes of Embryo Transfers Performed by Reproductive Endocrinology Fellows versus Faculty, an 11-year retrospective review. And Dr. Colleen Miller will be telling us a little bit about why she did the study, how she did it, and what she found, and then we're going to lead into the debate.
Dr. Miller, thank you. Thank you. Hi, everyone.
Good afternoon. I want to thank Pietro and Dr. Hill for inviting me to speak today, and obviously for selecting our article, which we're really excited about. I have to really start by giving credit to Dr. Samir Babayev at Mayo Clinic, really, for the idea of pursuing this research.
I was lucky to start my fellowship around the same time that he started as a new consultant, and so we kind of formed this mentorship around being the newbies. But one of the things that we were really impressed by at Mayo as far as being the new additions is just how involved the fellows were with embryo transfers and how many they performed over their three years of training. So as I'm sure you all experienced on the interview trail, there's a wide diversity of training experiences and fellowship, and not every fellow gets to perform live transfers.
So we felt like at Mayo, there's a long tradition of having fellows choose and select who they're going to do transfers on with the doctor of the day. And so having this long tradition, we felt like we were going to have a good number of transfers that we could talk about, and hopefully it would support this idea that fellows should be involved during their training. So within the REI division, we actually have our own database based on kind of our SART reporting that tracks all of our ART procedures.
So we were able to pull data from January 2009 through January 2020, and we ended up having 3,073 transfers to look at from about 1,500 unique patients. Fifteen fellows performed transfers over the course of our study and ended up performing about 1,225 transfers. So it was about 40% of the total transfers that we looked at.
The remaining transfers were completed by 18 different faculty members. And in our program, first-year fellows are required to complete 30 mock transfers, so under trans-abdominal ultrasound guidance with a faculty supervising before they can perform a live transfer. We also have a requirement of doing 10 IUIs, but that's not required to be completed before your first transfer.
It just has to be in the first year. So we looked at outcomes first among the fellows. So we actually stratified it by year and looked across the years to see if there was a difference between first, second, and third-year fellow outcomes, and there really was not.
So we saw some variations among each fellow, but there was no pattern as far as within each group. On average, the fellows completed about 100 transfers over their fellowship, but with the majority, about 75%, were completed in that first year, which is primarily clinical. Then we also actually looked at the first 30 transfers that were completed by the first-year fellows and compared that to any subsequent transfers that were completed in the first year, just to see if there was any kind of learning curve.
Surprisingly, actually, we found that those first 30 transfers had a higher clinical pregnancy rate and live birth rate compared to all the subsequent transfers in the first year. The only statistical difference between those two groups was that in those first 30 transfers, fellows tended to transfer more than one embryo, but when we corrected for that, the differences remained the same. And then when we looked at fellow versus faculty outcomes, we found no statistical differences.
The clinical pregnancy rate for fellows was 45% versus 43% for faculty, and the live birth was 40% for fellows versus 37% for faculty. There were a few demographic kind of statistical differences that we found. For example, faculty tended to perform more donor oocyte transfers, more frozen embryo transfers, and more transfers after PTTA.
But when we did kind of a fitted linear regression model, we found that there were no differences still. Other things we kind of adjusted for were age, BMI, number of embryos transferred, type of transfer catheter used, and the year that the transfer was done. So our primary conclusion was that we did not see that there was any detriment to clinical outcomes when fellows were allowed to perform live embryo transfers.
So really looking forward to the debate up here. Thanks so much. Thank you.
Khan Sai, this is going to be hard. I'm going to start with the pro side. It's really nice when we have data that supports your side.
I'm going to give everyone a chance to have opening arguments. I want each person on the pro side to give a little bit of why they think this is a good idea. And then we'll go to the con side and then hopefully have some healthy debate back and forth.
There's going to be an opportunity for questions at the end. So if you have one, write it down and Michael will pass around a microphone towards the end so we can get some from the live audience and virtual audience. But I'm going to turn it over to the pro side.
Make your best argument for why fellows should be doing transfers. So I'm going to thank Dr. you know, I accidentally dropped the microphone. Thanks Dr. Miller for that.
So I think the case is clear. I mean, the data from Mayo, I've been sitting here for 10 years in this room having this debate and Paul Brezina started it for, I mean, I don't think he necessarily started it, but he started it for me and my generation and 2014, Jen Eaton, 2018, the Canadians, the group at Iowa, now Mayo. What more do you need? We talked about this earlier.
At some point, you can't get all the data. You can't have all the time in the world. It is time to let fellows do transfers and not just, yeah, they can do a transfer, but they should be, the default should be fellows should do transfers and programs should be setting expectations with patients to do transfers.
Well, I want to thank Dr. Miller for an excellent paper. This is the kind of work that we need in our field because clearly, as Dr. Obertag noted, there have been multiple studies because resistance still exists, yet there's no other procedure that we ask physicians to do and not do it during their training. I think of anything we do, surgeries, egg retrievals, really complex patient management.
So I think for starters, it's really hard to justify and to say that we're doing our job in training our fellows if we don't allow them to actually perform the embryo transfer. That's the first thing. I think the second thing is that we have a responsibility to practice evidence-based medicine and evidence-based medicine tells us that it is absolutely safe and absolutely appropriate for fellows to be performing embryo transfers.
I think we know that there are concerns about patients. As we all know, many of us practice in self-pay settings where we are very concerned about patients' perspectives, but we have evidence that just as we talk with our patients about the evidence around single embryo transfer, around anything else that we do, we can talk with our patients about this evidence and make it possible. We also know that as we get better at teaching our patients and encouraging our fellows to advocate for themselves, and I'm very proud of my fellows in the audience who do a great job of letting their patients know where they are in their training.
This isn't an intern on July 1st. This is a very experienced, very well-trained physician who is capable of doing all parts of their patient's care, and this is something we need to be doing. I agree with everything that my colleagues on the pro side said.
I pose a question. When is the best time for a trainee or a physician to perform embryo transfers for the first time? Is it with an experienced teacher and mentor doing the ultrasound and helping, or is it when they get out in private practice in a hurried environment? I think the best thing for our patients is to do the transfers in a carefully controlled teaching environment. Second, our fellows have done transfers at least since 1993 in our program, and we have not seen, in fact, our fellows, we always choose the easiest patients first, of course, because that builds confidence all around, to the nurses and the fellows themselves, and usually our fellows have 100% transfer rate the first couple of transfers because we choose the young patients with the best quality embryos and the easiest transfers, and that builds a confidence that lends itself when they land in their jobs.
But beyond that, the arguments against seem kind of specious. You know, one argument is that, oh, it's an awake patient and they know it's a trainee and this is, you know, the patient will be very nervous. Well, you know, we do vaginal deliveries on awake patients and certainly trainees are doing that, much less well-skilled trainees often.
Or take C-sections on awake patients, or you can name many, many different things. And what's the other one? Well, it's bad for business because our competitors in private practice don't do this and they'll use it against us. Well, they might, but it's how you frame it, just as Erica said.
How do you frame this to the patients from the beginning? And it really helps if your fellows have their own patients because then they have a relationship with those patients from the start. All right. That's a pretty convincing argument for the audience here.
Kansai, do your best. Thank you very much. I mean, it's so nice to get this emotional support and the support that we might need for our confidence as we train.
I must admit, when I got the email asking me to participate, I was in a busy clinic. I skimmed it. I saw the title.
Fellows shouldn't do embryo transfers. We'd love for you to be there. I'm like, oh, wow, I'm going to be a prop for proof that fellows shouldn't do embryo transfers.
That's a little hurtful. But no, I agree. And I'm going to take a little bit of an unorthodox approach.
I'm going to agree with everything that the pro side said. I think that the data that we have is excellent. It's a great study.
It's a lot of embryo transfers to give us the confidence that after a training period, fellows or any provider who has undergone that training period has equivalent success rates with their embryo transfers, not just after a period of time doing live embryo transfers, but in the first 30 embryo transfers, the pregnancy rates, the clinical pregnancy rates and the live birth rates are equivalent, even when controlling for covariates, even when looking at the slight differences in demographics between fellows and attendings performing embryo transfer. So really this data gives us confidence that fellows don't need to be doing live transfers during their training because we have this excellent data to show us that after doing a certain number of mock embryo transfers to learn these skills and the variety of other training mechanisms that we have to teach these skills to fellows, that our pregnancy rates are going to be the same. We should take confidence from this that we don't need to worry about getting a certain number of embryo transfers during our fellowship training because with the right training outside of live transfers, we're going to perform just the same.
Well, thank you so much. And while this was a great study, thank you so much, Dr. Miller, it is a retrospective study and there are definitely limitations. Dr. Young said it himself, these patients are cherry picked.
You are giving the fellows, the easy patients, the ones who are going to get pregnant, it's going to bias the numbers. In addition, there was no data on... I think you're misquoting me. Just to be clear, I said we give them the easy patients to start with.
There is no data in here on difficulty of transfer. They didn't have any data on whether a stylet was used, whether the fellow started the transfer, but then ultimately it went under the attendings numbers because it was so challenging and difficult they had to take over. So this is a big limitation if we can even believe this data.
In addition, we have so many better tools that we can do. The first embryo transfers should be in simulation and we have a wonderful simulator. We had fellows here that came early to do that.
There was a 2015 article on FNS by Ryan Heitman et al. where it showed that those fellows that did the transfer simulator and then afterwards did embryo transfers, those that did the simulator had higher pregnancy rates in their first 10 live embryo transfers than those that did not. So we know that the simulator works and it's a great option and we should not be practicing on patients and sacrificing their care.
Additionally, embryo transfer is just the culmination of this huge investment for patients, of their time, of their finances, of technology, and their hopes, and they expect to not have a trainee doing this transfer. They want the most experienced person to be doing their transfer. So at Iowa we have a similar setup to Mayo.
We do 20 mock transfers and then the fellows are just expected to do the embryo transfers after that. So our fellows graduate probably having done more than 300 live transfers. And so we recently just presented our data at ASRM as well and we, again, did find that there was no difference between fellow and faculty embryo life birth rates.
And we also found that there was not a learning curve. We followed the pregnancy rates as the fellows went over their time in fellowship and everyone was at the mean of about 50% life birth rate. And so while we feel that this is this necessary experience for us to have in fellowship, the data doesn't support that, that there isn't actually a learning curve.
Dr. Miller found it in her study. McQueen et al. found it at Northwestern that there was not a learning curve.
We have seen that at Iowa. And so when you balance this patient expectation and all of these hopes and investment in this embryo, if it's not an experience the fellows need, give the patients their autonomy and what they want. Have at it.
So I would ask, should we also eliminate egg retrievals from fellowship training? Perhaps we could eliminate ultrasound training, surgery, medicine. In fact, we could maybe just get rid of fellowship training altogether. Y'all could hang out at the coffee shop for a few years.
You heard it here. Eliminate fellow training. This is fantastic.
And then start fresh. What is the point of training if not to learn and gain skills and gain the benefit of doing a new procedure with supervision and support? Oh, let me hit something. So I can't, I got, I'm going to let you talk in a second, but let me, let me.
Okay, so hold on. So we're talking about the simulation of the technique replacing an actual live embryo transfer. You need that training because you don't walk into a room and not talk to the patient who has, as you said, expended physical, financial, emotional energy at that moment.
And you're going to equate that experience in that 15 minutes to the five minutes you spent on a simulator. No, that's not how it is. That's why you need to do these live.
That's why you need to be in the room because an embryo transfer is a choreographed routine between you, the ultrasonographer, whoever that is, the partner, the embryologist, and whoever the hell else is in that room that's supposed to be in that room. And kind of dismissing it as just something that can be simulated or can be replaced by 30, 50, 100, two, you know, whatever, I think diminishes what we all agree is a very, there's a lot of importance to that moment. So I disagree with the premise of that as a claim.
I think, first of all, the data would suggest that that's not actually necessary, right? I mean, the practicing of a live transfer is not necessary. I think that's eloquently shown in this paper and many other papers. And I think, to Dr. Johnson's point, you know, there are many procedures that we train during residency that we cannot simulate.
You know, you cannot simulate a vaginal delivery. You cannot simulate a hysterectomy. At least right now, the tools that we have to simulate these techniques don't exist.
You cannot practice in a sim lab, you know, the techniques that you need to become an adequate technician with those. With a mock embryo transfer, you can simulate everything up to the point where either yourself or your embryologist plunges the embryo into the uterus. Everything is the same.
You can have full bladder, adequate preparation, the same tools, the same ultrasound, the same team. You can simulate 100% except for the depressing of a plunger. And if you want to add a plunger to your simulation in your mock embryo transfer, fine.
But, you know, I think this is one skill that you can actually adequately simulate prior to doing a live embryo transfer. Can I ask you a couple questions here? So it, I don't know. I heard that the most experienced person in the clinic should do the embryo transfers.
So I guess if a fellow graduates with no transfers and goes to a practice, they should not do embryo transfers. And then next year after that, unless they're the only one in the practice, they will continuously be the least experienced person. I don't think that's very feasible.
Practicing on patients, I heard that from someone. I mean, we all practice on patients, but where do you want to practice on patients? When you have guidance and expert mentorship? When you are prepped and you start with the easier and then go to the harder transfers? Or do you just want to practice on patients when you're out on your own, as increasingly fellows will be in their new jobs? And not needing to do something by the statistics and fellowship, you know, not needing is not the reason not to do it. There are reasons to benefit the fellow in their own growth as a physician to do those transfers and to feel comfortable doing those transfers.
Maybe technically it won't matter in some cases. But I would say that mock embryo transfers require actually a lot of extra personnel if you're going to do it the way you mentioned. And that's a drain on the clinic.
Why not have the fellows do the transfers once you've done a few of those? Why not put those talents to good use? Concerning your first point, I don't think it's that the patient wants the most experienced person there or the person that's done the most. I think they want their physician, and we want the patient experience to be the focus. Maybe a nurse practitioner did their intake.
The ultrasonographer sees them every day. The fellow did their IUI. But this is your one chance for you as the attending to do this for your patient.
And I think that's a big difference, too, between the other procedures that you were discussing. Why not let fellows do any procedures? I think that this is one that we can hold sacred for the attendings. Well, I guess it depends on whether your fellows have their own patients or not first.
If they have a relationship with a patient that is the strongest relationship, then I don't see that as an argument. I agree with what Steve said here. The assumption seems to be that fellows should not care for their own patients.
But, again, how are fellows going to learn to be independent practitioners if their training is just chunked out into little procedures? I mean, just as continuity of care is recognized as one of the most important facets of graduate medical education. It's required in residency. It's required in fellowship.
And that's because our fellows need to see a patient and see them through the whole process. We have seen universally. So our fellows see their own patients.
They see patients with insurance coverage. They see self-pay patients. They see the gamut.
And every single one of those patients has been happy for the fellow to be the person doing their embryo transfer because they've built that relationship with that patient and they've demonstrated to the patient that they're knowledgeable, that they are caring, and that they are able to guide them through this journey. Conside, is there ever a scenario in which you think a fellow may be allowed to perform an embryo transfer? And if so, when and how? That's certainly a difficult question as we as a whole think that fellows should absolutely not be doing these incredibly complex, difficult procedures that four years of OBGYN residency certainly did not prepare them for. I mean, traversing the cervix is a very difficult skill that we believe that you need those three years of watching your attendings do it during fellowship to be competent.
So perhaps after, you know, a third year about to take off for practice who has scanned for hundreds and hundreds of transfers and has done hundreds of IUIs, perhaps on the right patient you could consider it with great caution. Great caution. So, you know, I think what it comes down to is really the patient care experience.
And I think what the pro side is missing here is that we really should recenter our focus on what the patients want. So, yes, I think there are circumstances where fellows who have their own clinic patients who they follow through the entire process as though they were an attending, then we could just call them a proto attending and let them do an embryo transfer and pretend like they're an attending for statistical purposes. But, you know, I think what it comes down to is we shouldn't be shoehorning fellows into patients' lives for the purposes of, well, we want to make sure that we can tell applicants on the interview trail that we do a certain number of live embryo transfers and bolster our numbers that way.
You know, there was a paper that came out of one of the papers that's referenced in this paper that we discussed today, came out of England, 2019 paper, and they actually asked patients, who do you want performing your transfer? And the patients said, you know, 54% of them said that they wanted their provider, their clinician, their experienced clinician that they've chosen to come to for this aspect of their medical care. Once those patients were told, well, look, all the data says that there's really no difference in outcomes based on stage of training or fellow or attending. Who do you want providing your care? Who do you want doing your embryo transfer? 50% of patients still said, no, I want my doctor.
And I don't think that we should be shoehorning fellows in for the sake of fellow education if we have data to prove that it's not necessary for fellow acquisition or fellow skill acquisition. I'm hearing that there's 50% that would be fine with the fellow doing it, though. Did I hear that right? And if so, how do you prep the patient in your practice to let them know that the fellow may or may not be involved in their care all the way up until the end? Okay, I see the Jedi move to use the patient-centered approach against me and us here.
But let me say this. If you're truly patient-centered and want to make sure they have the best experience, it's all about setting expectations. And when you see the patient in the beginning, you introduce the patient to their care team.
You are part of the care team. You will be there to do the transfer because of the rotation. You may not be.
And if you're not there, it'll be one of the partners. Our fellows are our partners. They may be involved in your care.
So you can still be patient-centered by setting appropriate expectations and letting the fellow do the transfer. And when, as I mentioned before, embryo transfer is a ritual that is a culmination of this investment that everyone has made for that moment. And to have your physician there, whether it's the patient's physician or the patient's partner's physician there, and the fellow, which, again, is a partner in this game, to me, you're there.
They want you there. They need you there. They recognize after you're telling them that the technical piece is equivalent, but you're there reassuring them, oh, take deep breaths.
Speculum is a little uncomfortable. Let's stop for a second. I see you're very tense.
You're still driving the ship. So even though you might not be the technical piece as the attending because the fellow is just as equivalent, you're still there, and that's important to the patient. How do you combat the scenario where the patient says, I don't want trainees involved in my care at all? We tell them which phases of care the trainees may be involved in, and those patients are not appropriate for fellow embryo transfer, although I will say some of those people who say that really mean medical students and sometimes residents.
And when they find out that their doctor, who is a fellow, is a trainee, they are completely comfortable. So I think one can navigate that individually with each patient. But if a patient desires a particular doctor to do it, we try really hard to get that particular doctor to do it, be they a fellow or an attendant.
I have two patients in my practice who are my patients who prefer their fellow to do the transfer. I think we need to let our egos down a little bit and accept that I think we all, all of us in medical education, have that experience where we suddenly realize that our patient actually prefers our fellow to us, and we've just got to let that go. That's a great thing.
That's a great thing. That means you've got an amazing fellow. And so, you know, I think that I find, as was alluded to, that when patients say, I don't want a trainee in my care, then they realize the trainees they've already seen.
Oh, of course. I want Dr. Verilli or Dr. Eagle. Well, they're amazing.
Not like my image of what a trainee is. And so I think it calls upon us to do an ever better job of explaining to our patients what different types of trainees that, oh, they maybe had a really uncomfortable experience because, you know, my third-year medical student went in and took a history, and they were pretty uncomfortable and asked them some awkward questions. But to be clear that, you know, a physician who's been in training for five to seven years is, in fact, someone that they can trust and count on.
Constant, I'm going to ask you to put your thinking cap on for a second. In a world where fellows were performing live embryo transfers, and it's not a world you want to live in, Callie, how do you think you best prepare the fellow to be successful? How do you structure the training leading up to that first fresh transfer, be it with simulation, mock transfers, IUIs, catheter choice, ultrasound guidance? What's the secret sauce to set them up for success in a world that you don't want to live in? You know, so I think papers like the one that we're discussing today are really helpful at setting that up. So, you know, there are a lot of different strategies for preparing fellows or trainees in whatever setting to do a live transfer.
I don't think anyone is arguing that, you know, a fellow on day one of fellowship without ever seeing an embryo transfer catheter should be performing this difficult embryo transfer. But what we need to do is figure out what tools we need that we can standardize and in cases individualize to allow fellows to have the skill set that they need to be a fully functioning attending or a fully functioning fellow performing embryo transfers if that's the world we must live in. And I think this is a really good paper because, you know, it shows us that 30 mock embryo transfers provides fairly equivalent results.
The experience out of Iowa of 20 mock embryo transfers, I don't think there is a one size fits all solution. I think, you know, mock transfers are great. The simulator, you know, has been demonstrated to be effective.
IUIs, plus minus, I'm not sure if there's, you know, been a whole lot of great support to say that IUIs are the thing that we need to be doing. But, you know, we have these techniques. And I think what it's really incumbent on is fellowship programs, training programs to establish a clear protocol for their trainees to provide them with the skill set, the knowledge, and the confidence to be able to go into that room for their first live embryo transfer as a trainee or as an attending and be able to do a great job.
In the same way that we certify trainees to be competent on the robot training, where there's kind of a protocolized approach to ensure competence, how do you ensure competence in your trainees at your programs and do you track their outcomes? The second one's easier. We track our outcomes just like everyone. We look at success rates per transfer.
So that's easy. What do you do if they fall behind? I'm sorry? What if your fellow's pregnancy rate is not as good as your junior attending or senior attending? Well, that hasn't actually happened, but were to happen. We would do the same thing as we would do for an attending whose transfer rates are not as good as the other attendings.
We would provide additional. We'd take the person who has the best transfer rates the last two quarters, and we would have them precept the transfers with that person. You know, if it's egregious, obviously you might take a step back and do some more mocks under supervision, but we haven't found it necessary.
What was the first question? How do we prepare them? Doing a lot of mock transfers under ultrasound and preferably holding the catheter with a syringe just to mimic what you'll do in the actual transfer. Yes, a simulated transfer, otherwise known as a mock transfer under ultrasound. Yeah, we're pretty similar.
One of the things I'll add is we actually have our fellows run the ultrasound to get that experience of finding that catheter, making sure the uterus is in that sagittal view, and they get a lot of experience that way, navigating those retroverted uteri, the uteri that are oblique, and that actually helps them navigate those, prepare them for those difficult transfers because now they know how to talk to the ultrasonographer when they're actually doing the transfer. I would hazard to say sometimes that ultrasound is harder than the transfer. I have a question for you all.
As Dr. Omertag was mentioning, the team approach and trying to set the patient expectations, but what do you do when you go into the room and the fellow goes to sit down and then the patient says something like, oh, I thought you were doing my transfer, Dr. Omertag, where you know that the patient is in a difficult situation where they don't want to go against their physician but they might not blatantly want to speak their mind, but really you know they want you. Yeah, so I go in and I let them know, I introduce them to my partner, say this is my fellow, first year, second year, third year, we're going to be doing your transfer together today. So this is how we do it.
If it is their first one, I'll let them know before the fellow goes in and I'll basically say, look, I'm going to be there, they're going to get the process started, and I have the utmost confidence, blah, blah, blah. And I set that expectation and then I give them an opportunity to opt out and then we go in together and we have the conversation. Normally the conversation goes, hey, we're doing your transfer together, she'll be sitting, he'll be sitting, they'll be sitting, whatever.
And then we walk them through what the process is going to be. This is who's going to be in the room, this is the ultrasonographer, this is the fellow, I'll be standing here. I'm going to make sure the embryo is placed in the right spot before we deposit the embryo in the uterine cavity.
And then I stand there and I have conversation. What are we doing today? What are you guys doing after this? I'm basically setting the stage. We all have this system where we basically, again, this is a ritual, and you can simulate that ritual using the mock simulator and other venues, but it really helps when you have the patient who's actually giving you feedback, whether it's at the moment of putting the speculum in or emotionally in that moment when they're tearful and you're acknowledging that emotion right there.
I think that's what's important, I think, to the patient as much as, if not more, than who's actually at the perineum putting the catheter in. I don't recall that ever happening. We have those conversations before the patient gets to the transfer room, usually also on the same day.
We've heard a lot from our pro and con side, but we have a live audience here and a virtual audience. Micah, what questions are people presenting? We want to hear from this on-site audience in just a minute, so if you have questions, raise your hand. I'll walk around with the mic.
Just introduce yourself, say where you're from, and we'll get the questions. I want to give a quick shout-out to one of our live global audience members, Ryan Heitman, who's the division director at West Virginia University, texting me saying this is the most fun he's ever had listening to a fertility and sterility debate. But we've heard a lot about the embryo simulator.
If you did the training course yesterday, raise your hand. We had 18 fellows from around the country who did that course, and ASRM spent a lot of money and a lot of time developing that. One of the key people in developing that was Keith Ray, and Keith is here.
Keith, I just want to hear from you real quick what you think about how the simulator can play into the role of this debate that we're having for training fellows. Good afternoon, everyone. I'm Keith Ray with ASRM, and I'm the program director for the simulation program, and have been since development.
Thank you for all of you who participated yesterday. It was a great workshop. I commend this journal club live session and the panel.
I think my heart skipped a beat when I would hear a couple of the fellows talking bad about simulation, especially since you had been in my course before. So kudos to you, and kudos to Dr. Miller for the paper as well. ASRM, back in 2015, developed the simulator in partnership with VirtaMed, and we were addressing a gap in training, and that's a well-known gap that everyone in this room is aware of.
And so what we've done over the last six years is developed a curriculum-based simulation course, and so it's been very successful. And what that provides is the increase in skills and confidence so that you can use that in a clinical setting along with your attendings as a supplemental tool to getting to the live transfer point of your careers. And so it's been very successful.
Is there any questions about the simulation that anybody might have? The simulator? When's the best time for fellows to do it? Do you want all first-year fellows to do it in July so they can have two and a half years of fellowship ahead of them? So before the COVID shutdowns, almost 70 percent of all fellows had completed the course. So we were on track at that point to have all of the second and third years taken care of, so to speak, and then we would only focus on the first years. So yes, to answer your question, first, second, or third, we recently also published a paper in FNS back in April where we took 78 of our participants, we analyzed the data, and it showed a marked increase in confidence and skill building across all fellowship years, and regardless of whether the fellows were able to do live transfers or not.
So there was still improvement in skill and confidence. So our goal is, and we hope that we'll continue to work with SREI and the program directors and, of course, all of the fellows so that we can use this tool as a means to supplement what you're doing in a clinical setting. Thanks, Keith.
You're welcome. Thank you, Keith. So the first question from our panelists comes from online, and then I'll start walking around the room.
He's in France, and he says that in many European countries this isn't even an issue. This is a normal part of their training. What are the barriers in the United States specifically that this is even a question that we're debating today? It has to do with insurance costs and the large price that most of our patients are paying, as most states are not mandated to have insurance coverage.
So a lot of it is the psychological aspect of the patient has invested all this money in this process, and then you want to give them the best chance possible. I think a lot of it is also just tradition of this is the way it's always been done. This is the way we're going to continue to do it.
I think some of the largest. Are there patients that fellows shouldn't be doing their transfers? If so, which ones? So I think it always should be a discussion. I think, for example, I would not want my fellow to do their very first transfer in either a patient with a very known and expected difficult transfer or a patient who has a single embryo, nothing in the freezer, is at the end of their road.
And that's not because the outcome wouldn't be as good for the patient, but rather really more for the sake of the fellow to not put them in a situation that they would feel anxious about or put them in with a very poor prognosis patient where they might blame themselves and lose confidence as a result of what might be a transfer that we didn't have a high expectation that it would be successful. Just to break character for a moment to counter that argument, as a trainee on some of those difficult transfers, it's so reassuring to be sitting there and have your attending over your shoulder saying, try this, try this, maybe we need a different catheter. Or if you can't do it, you can tap out and your attending is right there.
And you don't have that after you leave training. You don't have that bird on your shoulder giving you confidence, giving you tips. I'm glad that I have done those difficult transfers, that last embryo, the patient who had a trachelectomy, the one you can't find.
Thank goodness I had wise, excellent teachers to help me through that. Micah. Hi.
I would like to perhaps turn this debate slightly on its head, and since we have a good amount of evidence that it is quite feasible for fellows to be performing embryo transfers, including live ones, my real question is why do physicians, fellows or attendings, need to be doing them, and have we considered the possibility of mid-levels, nurses, and other individuals as the default practitioner performing embryo transfers, and in fact almost all aspects of our fertility care? Can I take this one really quickly? We have 17 minutes left. Sarah, go ahead. I would just like to point out that there was a randomized controlled prospective study done in Scandinavia in 2014, 18, somewhere, where they in fact took 102 patients and 51 were randomized on retrieval day to either have a gynecologist doing their transfer or another 51 were randomized to having a midwife do their embryo transfer, and what they found was that the live birth rates were the same between the two groups.
I'm just going to leave it there. Thank you. Other questions from the audience? Question.
Tell us your name and where you're from and ask the question. Hi, I'm Josh Combs. I'm one of the third-year fellows at the combined federal program at the NIH.
I'd like to iterate the scenario one time. So the fellow's done the transfer and it failed. How do we deal with a patient who blames that failed transfer on the fellow, and do we offer that patient a staff-only transfer in the future? So, again, I think if you really believe in being patient-centered, but this is where the conflict can always be challenging because you're trying to be patient-centered and you're addressing their anxiety and their guilt.
Despite the efforts you can have to convince them that their failed cycle, I mean, what's the reason someone failed? Probably because of some embryo factor or some uterine factor. Not likely the technical piece. At least that's the conventional wisdom we operate under, that the technical component, unless the transfer took a long time, the evidence kind of suggests it's probably not making a difference.
So in those cases, you just, again, use your experience as a physician and say, look, I've been doing this a while, we've been having our fellows do this, this comes up. I can assure you your outcome is not a function of the fellow doing the transfer. The fellow has done 50 transfers, 300, or 30.
It's not because of that. However, we'll acknowledge your anxiety and your situation, and you may either make accommodations or you decide to be a hardliner and say no. And that's really just a welcome to reproductive medicine.
Micah. We have an audience question that is actually for the audience itself. Thank you.
Hi, I'm Ariel Bayer. I'm a third-year fellow at Montefiore in the Bronx, New York. And since we have this unique opportunity of so many fellows in the room, may I ask with a show of hands of the fellows who embryo transfers are a part of their training currently? And then may I see with a show of hands those who have not been able to have this as a part of their training? Too many hands still.
Too many hands but progress. Yeah, definitely too many hands but progress, because 10 years ago it was more like half and half. So we have the unique opportunity to be speaking to a group of fellows, but hopefully also a bunch of program directors that may be watching live or may be watching later.
What advice do you have for those programs that aren't currently incorporating fellows routinely in their embryo transfers to help get them started? So I would say, I will be honest to say my fellows advocated for having their own patients. And I thought, well, will every patient be happy seeing a fellow? Every patient is happy seeing a fellow. Our fellows get outstanding reviews from patients.
So I think that was the first big jump for us to say, you know, actually there are plenty of patients, and luckily patients can self-select. And so we look at it as allowing the patients to self-select at their first appointment. But if they select a fellow at that point, that has, without exception, gone very, very well.
And, again, for us that's been our strategy to give fellows the opportunity to do transfers and also maintain high patient satisfaction. So I would, you know, advise programs to think about including their fellows and seeing their own new patients. It also allows us as a practice to see more patients than we otherwise would.
So that's definitely a good thing as well. We do a very similar thing to your program. I think that it's all about framing and all about allowing some patient autonomy and with contact.
I mean, there are patients who are medical professionals who choose our fellows because of access and frequency of contact. And they value that, and they know that those fellows, if they have unusual instances occur, the fellows have backup and they feel completely comfortable. We have time for one more question from the audience, Micah.
Hi, my name is Victoria Jang. I'm the first-year fellow at Massachusetts General Hospital. Kind of piggybacking off of that idea of thinking about fellows training and incorporating that into the training, I was curious if you guys had any, like, I was in the embryo transfer course yesterday, and just speaking with a number of my co-fellows and the people that I've been working with, there's a lot of variegation with each program as far as when do fellows start learning this skill, how do they start it, do you have to do a certain number of mocks or IUIs beforehand.
How do your programs do that, and how do you guys, are there any efforts as far as for standardization or recommendations from, like, SREI or ASRM just thinking about how to standardize that protocol for training? We basically, we don't have, like, X number, but we, I mean, our fellows start doing transfers at the second half of their first year, and then they do it throughout the rest of their fellowship. And in that first half of their first year, they're doing probably close to 100 IUIs, and then they scan at the time of transfer with our ultrasonographers at their elbow, two weeks' worth of transfers, which probably translates to about 50 transfers, that they're the one running the ultrasound abdominally, and then they're ready to go. And those first couple, I'm a big fan of the afterload technique, which, you know, you put the catheter in there, you make sure you're in the right spot, and then you call for the embryo.
So that's how we start, and then we fly after that. I'm hearing there's an opportunity for SREI or ASRM to put together potentially a model curriculum for the programs that don't have this currently existing in their fellowship and have some evidence-based guidance on how to do this safely, how to do this well. So maybe the folks in the room hearing this conversation can continue the debate afterwards, but we're running out of time, so we have time for closing arguments, and I'm going to give the fellows an opportunity to break character here at the end, and we'll start from left to right, and just kind of your closing thoughts about today's discussion.
I remember when I interviewed for fellowship, I remember asking a lot about, do the fellows do transfers or do they not? And it wasn't something that was super important to me, honestly, when I chose, because I had friends who had graduated and said, it's not a hard skill. If you don't learn it in fellowship, it's not a big deal. Don't worry about it.
There's lots of other important things to learn. Being at a program where we do all of the embryo transfers, we have a similar setup to Mayo and WashU. When you start fellowship, you have to do 20 mocks, and as soon as you get those 20 mocks, one of our attendings will supervise you, and if they say, hey, you're doing an acceptable job, you start doing your transfers.
So we start doing transfers in September of our first year, and our first-year fellow did 165 transfers last year before she went to research. Having had this experience, I can't imagine not doing embryo transfer during training, because while there isn't a learning curve that's demonstrated, I can't imagine not having the expertise of my teachers, who've been doing this for years and are so good at it, and say, let's get this catheter, let's try this, let's do McRoberts, let's call in a sonographer to help us with this, because either the fellow scan or our attending scan, we don't usually have our sonographer scanning. So there are tips and tricks that make doing embryo transfer easier for those tricky patients.
So while it wasn't something that was important to me when I was looking for a fellowship, it really is now. It's so incredibly important. This is like the thing that makes us an REI.
We do embryo transfers and egg retrievals. So to have that career-defining skill before you leave training is really important. I don't think I can say it better than that.
You did a great job. I agree with everything she says. Also, coming from a program where we get to do our own transfers, I feel like it's the best place to learn when you have that support around you, 100%.
So I'm glad we can break character. I think we just need to get out of our own heads. I mean, there's been, I guess, a historical trend towards fellows not doing transfers, and it's almost like we've been gaslit for three years that we're not good enough, that this is too far beyond our skill set to do safely in a fellowship training program.
I think the data is adding up. There's clearly got to be some sort of training process before you get to a live embryo transfer. What the best mechanism is, I don't know.
I think this study goes a long way towards establishing something, but we just need to get out of our own heads. It's not the most difficult thing in the world. We've all done at least four years of an OB-GYN residency training program, and I think this is a great confidence builder to say that wherever you are, if you're doing transfers in training or if you're not doing transfers in training, you will do a great job when you finish.
You know, I think in some ways back to, so during my training, I did not do a single embryo transfer, and then I moved to a new state and a new practice, and my first two embryo transfers of my life were observed, and then I was on my own. And while I think I followed the typical curve of a few not good ones in the first ten, and then after that met, you know, was equal to everyone else in the practice, I think it was visible to patients that I was anxious at the very beginning, and I think that made me less able to put my patients at ease and less able to, you know, make sure that they were comfortable and that they felt that they had, you know, what I don't think patients deeply care about level of training or years of experience. It's am I with a provider who is capable and caring? And so I think as we see that the evidence shows that it is clearly appropriate, safe, and good for the patients for trainees to be doing embryo transfers, there really isn't much argument against it.
Yeah, I would echo that. The goal is just to make, again, the embryo transfer is a sacred ritual that you need to make sure the patients are comfortable, and there are a lot of ways to do that, and I think that's what we should be thinking about. And if the patient feels comfortable in that moment, whether it's a nurse practitioner, midwife, physician of 60 years, physician of 6 years or 6 weeks, or a fellow of 3 months, as long as they feel comfortable in that room, we're doing the right thing.
I think the question is going to shift away from whether fellows should do transfers to how many transfers the fellow should be doing before they complete training, and that question may end up getting pushed by groups like ACGME and ABOG. But I think that, truth be told, most transfers are pretty easy or relatively easy. It's the hard ones that really, really make you sweat and give you worry and maybe make you shake, and that's not a good thing to be doing in front of your couple that you're dealing with, and it's not great for your transfer either.
So I think that doing those hard transfers is going to be important. I think the simulator for that is really good. It gives confidence, but it's not the same, and so I think we're going to have to look towards how many transfers fellows need to do in real life.
All right, gang, that's all the time we have for today. Please join me in thanking our panel with a round of applause. And on behalf of Fertility and Sterility, I also want to thank my co-host, Micah Hill, and our panelists and SREI for allowing us to broadcast live from this meeting, again, our favorite journal club to host every year, and it's nice to be back in person.
Thanks to our live audience of fellows, our virtual audience. The recording is going to be available after we're done here today. I think if you have a program director that doesn't allow you to do transfers, maybe think about sending them the recording, and this will also be an episode in our upcoming podcast where you can listen.
Pietro, would you like to take a final audience poll and see which of our teams had the best debate today? By a show of hands, should fellows be allowed to perform fresh embryo transfers during their fellowship? The yeas have it. Thanks, everyone.
