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.

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.

Non-tubal Ectopic Pregnancies: Overview and Treatment via Local Injection.

Ectopic pregnancies account for 1.5% to 2% of all pregnancy in the United States. Of these, approximately 10% implant in nontubal locations, including the abdominal cavity, cervix, ovary, interstitial portion of the fallopian tube, broad ligament, the uterine cornua, or within a cesarean section scar. Because these pregnancies tend to present later than typical tubal pregnancies, they have been associated with greater maternal morbidity and mortality. Advances in ultrasound technology have allowed for earlier diagnosis of nontubal ectopic pregnancies, which in turn has led to the development of novel minimally invasive techniques to manage them. One of these methods involves the local injection of 1 of several agents directly into the ectopic pregnancy. In this article we provide a guide to this technique of local injection, including an overview of the potential agents that can be used, and review the diagnostic and specific ultrasound criteria, other possible treatment options, and overall outcomes for nontubal ectopic pregnancies.

Applying to subspecialty fellowship: clarifying the confusion and conflicts!

Of graduating obstetrics and gynecology residents, 40% apply for fellowship training and this percentage is likely to increase. The fellowship interview process creates a substantial financial burden on candidates as well as significant challenges in scheduling the multiple interviews for residents, residency programs, and fellowship programs. Coverage with relatively short lead time is needed for some resident rotations, multiple residents may request time off during overlapping time periods, and applicants may not be able to interview based on conflicting interview dates or the inability to find coverage from other residents for their clinical responsibilities. To address these issues, we propose that each subspecialty fellowship within obstetrics and gynecology be allocated a specified and limited time period to schedule their interviews with minimal overlap between subspecialties. Furthermore, programs in close geographic areas should attempt to coordinate their interview dates. This will allow residents to plan their residency rotation schedules far in advance to minimize the impact on rotations that are less amenable to time away from their associated clinical duties, and decrease the numbers of residents needing time off for interviews during any one time period. In addition, a series of formal discussions should take place between subspecialties related to these issues as well as within subspecialties to facilitate coordination.

Minimally Invasive Management of Ovarian Cysts During Pregnancy Using Ethanol Sclerosis.

Traditionally, the management of symptomatic ovarian cysts in pregnancy has been limited to laparoscopy or laparotomy with the associated morbidity. However, in select patients requiring intervention, the risks of surgery may be minimized with sclerotherapy. We present the first case report, to our knowledge, of ethanol sclerosis of an ovarian cyst during pregnancy. A description of the surgical technique to complete such a procedure is provided as well as a brief review of the current literature with respect to the use of sclerotherapy for the management of ovarian cysts.

"Pause" for Resident Education in the Operating Room.

Objective: To determine if asking residents to discuss their specific learning objectives with the attending physician prior to beginning a surgical case would improve the educational experience in the operating room. Study Design: This was a prospective nonrandomized cohort study utilizing a self-administered questionnaire. Prior to the intervention, residents and attendings were asked to fill out surveys evaluating the educational experience in the operating room. Subsequently, attending physicians were instructed to ask residents at the beginning of the surgery, "What are your goals for this surgical case?" During this intervention period, the same anonymous survey was filled out. Preintervention and postintervention answers were compared by t test and Fisher's exact test. Results: A total of 49 preintervention and 47 postintervention resident-attending survey pairs were collected. After implementation of the intervention, 100% of residents reported having surgical goals for the procedure as compared to 45% prior to the intervention (p<0.0001). Additionally, during the intervention residents reported they were better able to maximize learning opportunities and were more satisfied with their participation in the case. Attending physicians were more likely to be aware of resident learning objectives after the intervention. Conclusion: We propose the routine addition of an educational pause to the surgical time out.

The accuracy of surgeons' provided estimates for the duration of hysterectomies: a pilot study.

STUDY OBJECTIVE: To determine the accuracy of gynecologic surgeons' estimate of operative times for hysterectomies and to compare these with the existing computer-generated estimate at our institution. DESIGN: Pilot prospective cohort study (Canadian Task Force classification II-2). SETTING: Academic tertiary women's hospital in the Northeast United States. PARTICIPANTS: Thirty gynecologic surgeons including 23 general gynecologists, 4 gynecologic oncologists, and 3 urogynecologists. INTERVENTION: Via a 6-question survey, surgeons were asked to predict the operative time for a hysterectomy they were about to perform. The surgeons' predictions were then compared with the time predicted by the scheduling system at our institution and with the actual operative time, to determine accuracy and differences between actual and predicted times. Patient and surgery data were collected to perform a secondary analysis to determine factors that may have significantly affected the prediction. MEASUREMENTS AND MAIN RESULTS: Of 75 hysterectomies analyzed, 36 were performed abdominally, 18 vaginally, and 21 laparoscopically. Accuracy was established if the actual procedure time was within the 15-minute increment predicted by either the surgeons or the scheduling system. The surgeons accurately predicted the duration of 20 hysterectomies (26.7%), whereas the accuracy of the scheduling system was only 9.3%. The scheduling system accuracy was significantly less precise than the surgeons, primarily due to overestimation (p = .01); operative time was overestimated on average 34 minutes. The scheduling system overestimated the time required to a greater extent than the surgeons for nearly all data examined, including patient body mass index, surgical approach, indication for surgery, surgeon experience, uterine size, and previous abdominal surgery. CONCLUSION: Although surgeons' accuracy in predicting operative time was poor, it was significantly better than that of the computerized scheduling system, which was more likely to overestimate operative time.

Postinterview communication with residency applicants: a call for clarity!

The residency match is an increasingly competitive process. Communication from medical student applicants to programs varies, and the effect this has on their rank status is unclear. We assessed how obstetrics and gynecology program directors interpret and act on postinterview communication initiated by applicants by conducting an anonymous cross-sectional web-based survey of allopathic obstetrics and gynecology program directors. One hundred thirty-seven program directors (55%) responded to the survey. Twenty-nine percent would consider ranking an applicant more favorably if the applicant expressed interest (beyond a routine thank you) or if a faculty mentor personally known to the program director stated that the applicant was ranking the program first. Fifty-two percent indicated that they would rank an applicant more favorably if a mentor known to them endorsed the applicant as outstanding. Approximately 30% responded that applicants who did not communicate with their program were disadvantaged compared with those who did. Approximately 17% stated it was desirable to create additional specialty-specific guidelines regarding postinterview contact between programs and applications. Based on the wide variation in how program directors interpret and act on postinterview communication from applicants, residency programs should formulate and communicate a clear policy about whether they request and how they respond to postinterview communication from applicants and their mentors. This will establish a more level playing field and eliminate potential inequities resulting from inconsistent communication practices.