Fluoroscopically-Guided Hysteroscopic Tubal Cannulation: A Procedure for Proximal Tubal Obstruction.

Objectives: To evaluate the cannulation success rate, cumulative pregnancy, and time to intrauterine pregnancy rate following fluoroscopically-guided hysteroscopic tubal cannulation (FHTC) for infertile subjects with proximal tubal obstruction. Methods: This retrospective study evaluated subjects with unilateral or bilateral proximal tubal obstruction on hysterosalpingography, who failed concomitant selective salpingography and subsequently underwent FHTC at the time of a hysteroscopy performed for findings seen on sonohysterography. FHTC employed a Novy Catheter (CooperSurgical, Inc, Trumbull, CT.) with or without the 3 French inner catheter and guidewire, to cannulate the occluded fallopian tube(s), followed by the injection of HypaqueTM (Amersham Health, Inc, Princeton, NJ.) contrast under C-arm imaging. Technical success rates, complications, post-procedure pregnancies, and average time from surgery to pregnancy were evaluated. Results: Thirty-two women between January 1, 2017 and December 31, 2019 met the entry criteria and underwent FHTC. Of those women with bilateral obstruction, 6/6 (100%) of subjects achieved at least unilateral patency, while patency was achieved in 23/26 (88.5%) subjects with unilateral obstruction. Twenty-nine of 32 (90.6%) subjects had at least one tube successfully cannulated with 34/38 (89.5%) of proximally obstructed tubes opened. Asymptomatic tubal perforation occurred in 1/38 tubes (2.6%). Ten subjects (34.5%) achieved intrauterine pregnancies without in vitro fertilization in an average of 64.9 days from the procedure. There were no multiple pregnancies and one ectopic pregnancy. Conclusions: FHTC is a safe, effective, incision free procedure that results in 90% of tubes successfully cannulated, and an observed short time to intrauterine pregnancy.

Training for the future.

PURPOSE OF REVIEW: The aim of this study was to review the evolving field of Reproductive Endocrinology and Infertility (REI) and describe the current and future challenges REI fellowship programmes in the United States are facing. RECENT FINDINGS: The field of REI continues to rapidly evolve largely due to the tremendous advances within the assisted reproductive technologies (ARTs). Alongside this evolution, there is a lessening emphasis on graduates being proficient in all aspects of REI. Ongoing revisions to the REI fellowship structure reflect these changes in technology and contemporary practice patterns. SUMMARY: REI is a rapidly evolving field and fellowship training is continually adapting to meet the changing landscape of our field.

Society for Assisted Reproductive Technology advertising guidelines: How likely are member clinics to maintain compliance after resolving their violations?

OBJECTIVE: To evaluate the Society for Assisted Reproductive Technology (SART) member in vitro fertilization centers' compliance with SART's advertising guidelines after delayed correction of previous violations. DESIGN: Retrospective cohort study. SETTING: Internet. PATIENTS: None. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Clinics that were cited for noncompliance with SART advertising guidelines in 2019 and exceeded the two-week grace period in correcting their violations were studied. These clinics were rereviewed in 2020, at least 6 months after their initial citation, for violations of SART advertising guidelines in all six categories: supplemental data noncompliance, link to SART Clinical Summary Report and disclaimer statement missing, unsubstantiated claims, statements denigrating other clinics, and claims of superiority. RESULTS: In 2019, 44 (27%) of 161 of clinics reviewed by the SART advertising committee had at least one violation that was eventually resolved but not within the two-week grace period. On rereview in 2020, one clinic had not renewed its SART membership and 10 (23%) of the remaining 43 clinics were noted to have violations at the subsequent review. Improper presentation of supplemental data was the most common violation category in both the initial review, 32 (73%) of 44 clinics, and on rereview, 7 (70%) of 10 clinics cited a second time for violations. CONCLUSIONS: Of the in vitro fertilization clinics with previous violations with delayed correction in 2019, 77% were subsequently compliant when reevaluated in 2020, indicating that advertising committee disciplinary and educational measures were largely effective. The most common citation for both years was maintaining consistent and transparent supplemental data on their websites.

Well-being in trainee and faculty physicians.

Background: Physician well-being remains a critical topic with limited information concerning the impact of the progression of training and duty hours. To date, our knowledge and interventions have not adequately addressed these issues. We assessed differences in well-being across the USA: (1) between all post-graduate trainees and their academic core faculty; (2) between all obstetrics and gynecology trainees and their academic core faculty and (3) during the progression of training within obstetrics and gynecology (OB/GYN).Methods: A cross-sectional study analyzing responses to well-being questions included in the 2017-2018 Accreditation Council for Graduate Medical Education (ACGME) surveys given to all U.S. trainees and core faculty. Results: More than 85% of all U.S. physician-trainees and faculty surveyed responded. Respondents included 128,443 trainees from all specialties combined, 5,206 OB/GYN residents and 799 OB/GYN subspecialty fellows. A total of 94,557 faculty from all specialties combined, 4,082 general OB/GYN faculty and 1,432 sub-specialty OB/GYN faculty responded. Trainees were more negative than faculty for the majority of questions for both all trainees combined and within OB/GYN when progressing from resident to subspecialty fellow to subspecialty faculty (p ≤ 0.05). Questions focusing on work satisfaction (e.g., pride in work) were more negative for residents compared to fellows and for fellows compared to faculty. In contrast to work satisfaction, responses to the question 'Felt the amount of work you were expected to complete in a day was reasonable' showed either no difference or higher scores for trainees compared to their faculty. Conclusions: Although an issue for all physicians, well-being impacts trainees more, and differently, than faculty and well-being improves during training from resident to fellow to faculty. Survey responses suggest that interventions should focus on workplace satisfaction over workplace environment areas and further limitations in duty hours are unlikely to improve physician well-being.

Perceptions and lessons from web-based interviews for the reproductive endocrinology and infertility fellowship application cycle.

OBJECTIVE: To evaluate the experience and perceptions of reproductive endocrinology and infertility fellowship applicants and program directors (PDs) regarding the current and future use of web-based interviews (WBIs). DESIGN: Cross-sectional study. SETTING: Nationwide cohort. PATIENT(S): Reproductive endocrinology and infertility fellowship applicants and PDs participating in the 2020 application cycle. INTERVENTION(S): Anonymous survey sent to applicants and PDs. MAIN OUTCOME MEASURE(S): Descriptive study evaluating the experience and satisfaction of applicants and PDs with WBIs. RESULT(S): Forty-six percent of applicants and eligible PDs responded to our survey. Most applicants and PDs responded that WBIs were adequate for conveying a sense of a program's strengths, faculty, diversity, clinical training, and research opportunities, but less than half responded that WBIs were adequate in providing a sense of the program's clinical site and facilities. After WBIs, both applicants (73%) and PDs (86%) were able to rank with confidence. The cost of WBIs was significantly lower for both applicants (median: $100) and programs (median: $100) than the costs previously reported for in-person interviews. The applicants interviewed at more programs than they would have if the interviews were on-site, and Zoom was the highest rated platform used. Most applicants and PDs responded that WBIs were an adequate substitute, and that they should continue after the coronavirus disease 2019 pandemic. Furthermore, most of the PDs were planning to continue to use WBIs in some capacity. CONCLUSION(S): Both applicants and PDs had favorable experiences with and perceptions of WBIs, and most endorse the continued use of this interview modality. The findings of this study can help guide and optimize future WBI practices.

Society for Assisted Reproductive Technology advertising guidelines: How are member clinics doing?

OBJECTIVE: To examine whether Society for Assisted Reproductive Technology (SART) member in vitro fertilization (IVF) centers adhere to the Society's new advertising policy, updated in January 2018, and evaluate other services advertised by region, insurance mandate and university affiliation status. Historically, a large percentage of IVF clinics have not adhered to SART guidelines for IVF clinic website advertising and have had variability in how financial incentives and other noncore fertility services are advertised. DESIGN: Cross-sectional study. SETTING: Not applicable. PATIENT(S): None. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Adherence of SART participating websites to objective criteria from the 2018 SART advertising guidelines. RESULT(S): All 361 SART participating clinic websites were evaluated. Approximately one third of clinics reported success rate statistics directly on their websites, but only 52.6% of those clinics reported current statistics. Similarly, only 67.5% of SART member clinics included the required disclaimer statement regarding their outcome statistics. Only 10.5% of websites were wholly compliant with SART guidelines regarding presentation of supplemental data. There were no significant differences between academic and nonacademic centers, programs in mandated versus nonmandated states, or East versus West Coast clinics in any of these areas. CONCLUSION(S): Many of the SART member websites failed to adhere to core guidelines surrounding reporting IVF clinic success rates. Consideration for additional education and streamlining as well as simplifying success rate advertising guidelines is recommended.

A Systematic Review and Meta-analysis of Surgical Treatment of Ectopic Pregnancy with Salpingectomy versus Salpingostomy.

OBJECTIVE: To evaluate the fertility outcomes of salpingectomy compared with those of salpingostomy among patients treated for tubal ectopic pregnancies, including a separate analysis of women with risk factors along with a review of the surgical technique. DATA SOURCES: Systematic review and meta-analysis from 1990 to the present through PubMed, Embase, CINAHL, and Ovid MEDLINE. The search string included "tubal pregnancy" or "ectopic" as well as "salpingectomy" and various terms describing salpingotomy. METHODS OF STUDY SELECTION: Articles studying women who underwent surgical management of an ectopic pregnancy and the contrasted outcomes of salpingectomy vs salpingostomy were reviewed. The primary outcomes included subsequent intrauterine pregnancy (IUP) and repeat ectopic pregnancy (REP). TABULATION, INTEGRATION, AND RESULTS: Two randomized controlled trials (RCTs), which consisted mostly of patients classified as low risk, and patients from 16 cohort studies were included. In the RCTs, there was no significant difference in the odds of subsequent IUP in patients who underwent a salpingectomy compared with those who were treated with salpingotomy (odds ratio [OR] 0.97; 95% confidence interval [CI], 0.71-1.33). However, a significant and clinically meaningful difference was noted in the cohort studies, with the patients having a lower chance of IUP after salpingectomy (OR 0.45; 95% CI, 0.39-0.52). No significant difference was noted in the OR for a REP in the randomized trials (OR 0.77; 95% CI, 0.41-1.47), but the patients followed in the cohort studies had a cumulatively higher risk of REP after a salpingostomy (OR 0.73; 95% CI, 0.60-0.90). The subgroup analysis examining women within the studies with risk factors for tubal pathology found an even more impressive lowering in the odds of a subsequent IUP in patients classified as at-risk who were treated with salpingectomy (OR 0.30; 95% CI, 0.17-0.54), with a change in the direction of the odds for an REP rate favoring those who were treated with salpingostomy (OR 1.96; 95% CI, 0.88-4.35). CONCLUSION: Salpingectomy has clear advantages over salpingostomy, and RCTs consisting mainly of patients classified as low risk show no difference in outcomes between salpingectomy and salpingostomy. However, in cohort studies inclusive of all patients, the likelihood of a subsequent spontaneous IUP is decreased in patients treated with salpingectomy, and salpingostomies may be especially underused in women with risk factors for tubal disease.

Can I Get a Suggestion? Medical Improv as a Tool for Empathy Training in Obstetrics and Gynecology Residents.

BACKGROUND: Physician empathy is associated with improved patient outcomes. No studies have examined the outcomes of medical improvisational (improv) training on empathy. OBJECTIVE: Our aims were to determine whether an improv workshop is an effective tool to deliver empathy training for obstetrics and gynecology (OB-GYN) residents, and whether that effect is sustained over time. METHODS: We conducted a prospective cohort study of OB-GYN residents undergoing empathy training through 4 improv games in a 1-hour session. Empathy surveys (score range 20-140) with validity evidence were administered 2 weeks prior to empathy training, immediately after, and 1, 3, and 6 months later. Fisher's exact test, Student's t test, and Wilcoxon rank sum test were used to compare statistical differences at each post-intervention assessment. RESULTS: All 22 invited residents participated in empathy training. Empathy scores improved immediately after (120.0 ± 9.8 versus 113.1 ± 10.6, P = .026), though they regressed toward baseline through 6 months (116.3 ± 11.0 versus 113.1 ± 10.6, P = .43). When asked on a scale of 1-5 how much the workshop would impact their work, there was an increase in scores both immediately after (mean 3.5 versus 4.6, P < .001) and 1 month later (mean 3.5 versus 4.1, P = .039), but this difference disappeared at 6 months. CONCLUSIONS: Using improv comedy to deliver empathy training is associated with a minor improvement in empathy scores in OB-GYN residents, which decreased at 6 months. Residents found the activity to be acceptable and reported the training would impact their clinical practice.