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Testosterone Supplementation in Women with Diminished Ovarian Reserve

Purpose: To evaluate the efficacy of transdermal testosterone as an adjuvant to the standard IVF protocol to improve outcomes in women with diminished ovarian reserve (DOR). 


Background: Women with DOR have extremely low pregnancy rates after IVF cycles, and there are currently few treatment options available. Testosterone supplementation may improve ovarian response to stimulation via enhanced folliculogenesis. 


Methods: This retrospective cohort study analyzed 83 IVF cycles based on inclusion criteria of age < 42 and diagnosis of DOR (basal FSH > 10, AMH < 1, antral follicle count < 6, or history of poor response [< 4 follicles]). Cycles in the control group were carried out using the standard IVF protocol while cycles in the treatment group involved the addition of transdermal testosterone prior to ovarian stimulation. Four primary outcomes were evaluated: total number of oocytes retrieved, number of mature oocytes retrieved, number of embryos generated, and pregnancy potential of the embryos.  


Results: Pretreatment with transdermal testosterone had no impact on the total number of eggs retrieved after ovarian stimulation. Testosterone had a negative impact of the number of mature oocytes retrieved, but had no impact on the number of embryos generated from those oocytes. Pregnancy rates between the treatment and control groups were no different per embryo transfer, but were lower per cycle initiation with testosterone therapy.


Discussions: Within this study population, retrospective analysis of testosterone therapy revealed no improvement in IVF outcomes. A randomized controlled trial is recommended to further investigate this association. 

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Patient Care, Medical Knowledge, GME, CME, Problem-Based Learning, Team-Based Learning, Reproductive Endocrinology & Infertility,

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Teaching Lesbian, Gay, Bisexual, Transgendered, and Queer Family Building in a Third Year OBGYN Clerkship

Purpose: To explore third year medical students’ fund of knowledge and attitudes about LGBTQ family building and third party reproduction.


Background: Medical student knowledge and attitudes about family building for LGBTQ families and third party reproduction (TPR) varies based on student prior experience and pre-clinical teaching.  The OBGYN clerkship is a unique opportunity for students to learn medical knowledge and reflect on attitudes about this subject.


Methods: A quantitative study of knowledge and attitude among third year medical students done after IRB approval. The intervention consisted of a one hour lecture on TPR and participating in a group discussion about LGBTQ family building. Students (231) completed a survey asking about their knowledge and attitudes prior to starting the rotation and 178 completed the survey following the intervention. Survey respondents rated items using a Likert scale and completed a knowledge assessmented. Changes in knowledge scores were investigated using t-tests.


Results: Survey respondents were 51% female, 48% male, 1% gender non-conforming; heterosexual 93%; and partnered 59%. Comfort with same sex couples was endorsed by 92%. 56% of students felt that opting out of assisting a patient with family building was not an option. Fertility knowledge increased from after intervention significantly (p<0.0001). Some students, 29%,  thought that infertility was hard to discuss, but 67% felt it would be hard to discuss for same sex couples.


Discussions: Medical students’ fund of knowledge was increased with lecture and small group discussion about TPR and LGBTQ patients. Students report being comfortable with TPR and LGBTQ families but have some discomfort with varied pathways to parenthood. Most feel that opting out of care for LGBTQ families is not an option. 

Topics: CREOG & APGO Annual Meeting, 2018, Student, Faculty, Clerkship Director, Medical Knowledge, Professionalism, Interpersonal & Communication Skills, UME, Lecture, Advocacy, Reproductive Endocrinology & Infertility, Sexuality,

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Resident education in Reproductive Endocrinology and Infertility: A Systematic Review of the Literature

Objective: Training obstetrics and gynecology (OB/GYN) residents in the area of reproductive endocrinology and infertility (REI) presents unique challenges. The objective of this systematic review was to summarize the available peer-reviewed literature on OB/GYN resident training in REI.

Study Design: Along with the syllabi from APGO/CREOG meetings from 2003-2012, a search of PubMed, Web of Science, MedEdPortal was conducted using the terms: "reproductive medicine or reproductive endocrinology or infertility" and "graduate medical or resident education." References from selected articles were also reviewed. Publications referencing training of OB/GYN residents in REI were included in the review.

Results: A total of 90 articles, 7 abstracts, and 15 educational tools were identified by the search and 7 articles, 2 abstracts, and 1 educational tool were found to meet inclusion criteria on further review. Reported outcomes included perceived and objective measures of knowledge. Overall, the studies suggested that increased time on the REI rotation improves perceived knowledge and competency. Didactics in the format of a lecture series (in person or electronic based)or problem (case) based learning, self-administered or interactive with faculty, also appear to enhance resident training in REI. Interventions appeared most effective in early years of postgraduate training.

Conclusions: There is limited education literature on resident training in REI. A dedicated rotation early in training with sufficient time and didactics, either faculty directed or self-administered, appear to enhance resident training in REI.

Topics: Reproductive Endocrinology & Infertility, GME, Medical Knowledge, Patient Care, Resident, 2013,

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Objective(s): A required component of resident Obstetrics & Gynecology (Ob/Gyn) training is Reproductive Endocrinology and Infertility (REI). The delivery of this subspecialty information in an already crowded curriculum is challenging. We sought to identify residents’ perceived barriers to REI education and assess the value of the American Society of Reproductive Medicine’s (ASRM) eLearn modules.

Study Design: All residents of one academic Ob/Gyn residency program were surveyed regarding perceived barriers to REI education. The REI curriculum was modified to include the ASRM eLearn modules. Residents were asked to rate the educational value of these modules. Descriptive analyses were performed.

Results: The survey was completed by 33 of 34 residents (97%). The majority of residents (78%) reported exposure to REI prior to residency. Although over 60% of respondents had had at least one REI rotation, 74% reported their REI knowledge as “Fair” or “Poor.” Barriers to learning included: limited time on rotation, lack of patient ownership, insufficient didactics, and patients not welcoming of trainee involvement. Residents found the ASRM eLearn modules easy to use and would recommend them to their peers as a learning tool. Following completion of the rotation 78% of residents rated their REI knowledge as “Good” or “Very Good.”

Conclusions(s): REI is a difficult area to incorporate into Ob/Gyn resident education. Knowledge of the perceived barriers to learning will help guide rotation restructuring and improve REI education. The ASRM eLearn modules are a valuable resource that can help target didactic deficiencies due to the limited rotation time.

Topics: 2014, Resident, Osteopathic Faculty, Residency Director, Residency Coordinator, Medical Knowledge, GME, Virtual Patient, Simulation, Independent Study, Reproductive Endocrinology & Infertility,

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Resident Opinions on Assisted Reproductive Technology: Status of Ethics Education in Ob/Gyn Programs

Abigail A. Delaney, M.D.
University of Louisville and University of Nebraska Medical Center, Louisville, KY
Study Objectives: Assisted Reproductive Technology (ART) has long been a source of controversy. Despite this, greater than 2% of all infants born in the United States yearly are conceived using ART. We conducted a survey to assess both the beliefs of those in training with regard to ART and the status of ethics education within US Ob/Gyn residency programs. The last survey of Ob/Gyn residents regarding ethics education was published in 1994 and did not assess education regarding ART.

Methods: The survey was developed with the help of the University of Nebraska Medical Center’s College of Public Health and the Ethics Committee from the American College of Obstetricians and Gynecologists (ACOG). It consisted of 25 questions covering patient demographics, specific ethical scenarios and referral for ART, and ethics education. The survey was sent electronically to all enrolled US Ob/Gyn residents using the ACOG database in October 2010.

Results: 285 surveys were returned. Among the respondents, 77 (27%) were in their first year of residency while 66 (23%), 74 (26%) and 68 (23.9%) were in years 2, 3, and 4, respectively. Mean age of respondents was 29.8 with a range of ages 25-44. 238 (87%) were female, and 204 (76%) were Caucasian. All states with residency programs were represented except for Iowa and Mississippi. Religious preferences of respondents were as follows: Roman Catholic (23%), Non-Evangelical Protestant (17%), all other religions (24%), Atheist/Agnostic (11%), none or no religious preference (25%). Upon analysis of the clinical scenarios posed in our study, the following percentages of respondents would not recommend referral for ART: patient’s partner is female (8%), patient is not married (11.6%), patient plans to be a single parent (14.4%), patient has 5 healthy children (38.7%), patient has HIV (40.4%), patient’s life expectancy is <5 years (74.7%), patient is 50 years old (75.9%) and patient with 25% risk of death in pregnancy (91.7%). With regard to residency program characteristics, only 30% of respondents stated that their program addressed bioethics. Thirty-six percent felt inadequately trained to deal with ethical issues such as those posed in our clinical scenarios. The survey revealed the following statistically significant findings: 1) those with more frequent religious attendance gave more weight to the importance of religion in medical decision making (p < 0.001) and 2) those with more frequent religious attendance were less likely to have an intention to recommend ART (p=0.037).

Conclusions: 1.) At the resident physician level, attendance and participation in religious activities influences medical decision making and adversely affects referral for ART. 2.) The data suggests that a more robust and comprehensive reproductive ethics curriculum including ART needs to be implemented in U.S. residency programs.

Key Words: Assisted Reproductive Technology, Ethics education

Topics: CREOG & APGO Annual Meeting, 2014, Resident, Residency Director, Medical Knowledge, Professionalism, GME, Reproductive Endocrinology & Infertility,

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Case-based Learning Using an Audience Response System in Reproductive Endocrinology and Infertility

Emily R. Penick, MD Madigan Army Medical Center, Tacoma, WA
Objective: To determine if the implementation of a case-based learning curriculum with an audience response feedback system (Turning Point ®) facilitates subspecialty learning of Reproductive Endocrinology and Infertility in an OB/GYN residency program.

Methods: This is a retrospective cohort study designed to evaluate the effectiveness of case-based, audience response program for OB/GYN residents at Madigan Army Medical Center over the duration of academic years spanning 2008-2012. The residents’ performance in the subspecialty area of RE/I was compared on the national in-service examination for OB/GYN (CREOG) to the other CREOG specialty subject areas. The Wilcoxen Sign Rank Test was used to compare the change in raw percentage correct score for each postgraduate year level residents’ performance in each subject area. A p value of < 0.10 was determined to be a significant difference in mean test scores when compared to the scores from previous years in the same postgraduate level.

Results: Improvement in performance by Madigan residents on the CREOG exam was noted in the specialty of RE/I, demonstrated by an increase in the percentage number of items answered correctly throughout each year of residency. This was not the case for the remaining subject areas. In addition, a statistical difference (p ≤ 0.10) in each year was noted in mean scores as residents progressed from first through fourth years of residency.

Conclusion: A case-based teaching format with the use of an audience response system provides an efficient learning paradigm which has been demonstrated to be an effective strategy to assist residents in acquiring knowledge in specific subject areas.

Key Words: Cased-based, audience response

Topics: CREOG & APGO Annual Meeting, 2014, Resident, Residency Director, Medical Knowledge, GME, Assessment, Problem-Based Learning, Reproductive Endocrinology & Infertility,

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Committee on Fellowship Training in Obstetrics and Gynecology: A needs assessment

Carrie L. Bell, MD

R Kevin Reynolds, MD, Peggy Engel , Timothy RB Johnson, MD

Background: APGO serves educators focused on women’s health by providing resources and support. Faculty in Obstetrics and Gynecology rely on APGO for this vital role. Currently, no unifying organization or committee exists for fellowships in Obstetrics and Gynecology. In 2010, a group of educators committed to the training of fellows formed a Committee on Fellowship Training in Obstetrics and Gynecology (COFTOG). The group determined that a needs assessment survey would best outline and direct the goals and objectives of the new group.

Objective: Survey the fellowship directors of OB/GYN based fellowships as a basis for the new Committee on Fellowship Training in Obstetrics and Gynecology.

Methods: A survey was designed; 5 demographic questions and 15 survey questions. The survey was entered into Survey Monkey. Contacts were identified gynecology oncology, maternal fetal medicine, reproductive endocrinology and infertility, female pelvic medicine and reproductive surgery, family planning, minimally invasive surgery, breast, pediatric and adolescent gynecology, genetics, and women’s health. The survey was sent to the contact lists. For specific fellowships, the national organization requested the survey for approval and subsequently, the organization sent it out to fellowship directors. The results were collected anonymously by Survey Monkey. The results were compiled and analyzed. The project was determined to be IRB exempt.

Results: There were 85 completed surveys from an estimated 250 possible responses; 34% response rate.. Thirty nine percent were MFM directors and 10-17% of surveys completed by family practice, FPMRS, REI and Gyn Onc. A national committee focused on fellowships was desired by 66% of respondents. 11% had formal training to be a fellowship director with twenty percent having served as a clerkship or residency program directors previously. 37% had participated in a faculty development course to help in their role as fellowship director. Sixty four percent thought a fellowship director school would be helpful. When asked about a central repository for evaluation, curricula, policies and organization, 68-70% responded in the affirmative. Specifically, directors asked for a national group to help with requirements from and reporting for national organizations (ABOG and ACGME), resolution of common problems, mental health, evaluation, training objectives and competencies. Two respondents wrote: "Have been looking to APGO for a long time to pick up the mantel. Have attended these meetings to pick up whatever points I could". "An APGO based organization may be able to provide some benchmarks to judge your program by, such as didactic schedules, curriculum, faculty supervision, etc."

Conclusion: Fellowship directors welcome APGO’s involvement and support in the form of COFTOG to provide support through faculty development and consolidation of resources for general use to improve the education of fellows.

Topics: CREOG & APGO Annual Meeting, 2013, Resident, Faculty, Residency Director, Systems-Based Practice & Improvement, GME, Assessment, Gynecologic Oncology, Contraception or Family Planning, Pediatric & Adolescent Gynecology, Minimally Invasive Surgery, Reproductive Endocrinology & Infertility, Female Pelvic Medicine & Reconstructive Surgery, Maternal-Fetal Medicine, Sexuality, Genetics,

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Robotic Surgery: The Davinci Uncoded

Soorena Fatehchehr, MD University of Oklahoma Tulsa School of Community Medicine, Tulsa, Oklahoma

Elisa Ramunno, JD , Amber Bledsoe, MD , Michael O. Gardner, MD, MPH , Nora M. Doyle, MD, MPH, MSc

Objectives: Robotic surgery initially designed for battlefield surgery by the U.S. military, became FDA approved for gynecological surgery in 2005. Current uses of robotic surgery include: tubal reversal, myomectomy, hysterectomy, sacrocolpopexy, and oncology procedures. Robotic surgery represents an educational challenge. It is associated with a significant learning curve and a large amount of time and energy is necessary to develop and maintain skills. Currently, robotic training for inexperienced, practicing surgeons is primarily done at sponsored day or weekend courses, with limited proctorship opportunities. Ideally, fellowship training could provide a structured comprehensive program to acquire this skill set. To more fully understand the impact of robotic surgery on fellowship education, we developed a survey to evaluate the current state of robotic training in US fellowship programs.

Methods: A 45 point questionnaire was sent to all Gyn-Onc, REI, UroGyn, MIS fellows and Fellowship directors . OU IRB approval was obtained prior to study onset. We gathered information on demographics, including size of fellowship programs and procedures performed. Univariate and multivariate analysis were performed where appropriate. A p value of less than 0.05 was considered significant.

Results: 546 surveys were sent and 102 responses were collected. Of these, 2/3rd were Fellows and 1/3rd were Fellowship Directors. Our responses were equally distributed from all four fellowships surveyed. Over half of the fellowships reported that they were doing <10% of their surgeries vaginally. 70% responders stated 10 - 40 % of their surgeries done with robot. 80% of fellowship programs are performing at least 10% of their surgeries robotically. 95% reported that conversion to laparotomy occurred < 10% of the time. GYN ONC reports treating 34% of endometrial and 23% of cervical cancers via the robot. Minimal invasive fellowships noted 28% Hysterectomies, 31% Myomectomies, 15% Pelvic Organ Prolapse (POP), and 4% Paravaginal repair were done with the use of the robot. Uro/gyn fellowships stated 40% Sacrocolpopexy, 27% POP were done with the robot. REI fellowships reported robot use in 12% LOA and tubal reanastomosis, 14% hysterectomies, 15% myomectomies, and 5% endometriosis cases. Approx 70% programs report that there is robotic training in the fellowship curriculum. 25% of programs have > 25 hours dedicated specifically to robotic training. 80% report hands-on training, > 50% report that simulator training is available. Finally, 50% of programs report their graduating fellows have > 50 robotic cases at completion of their fellowship.

Conclusions: Robotic surgery has become an accepted modality nationally. Systematic approach for training all GYN fellows appears to offer solutions to how we learn the robot. Incorporation of resident education remains uncultivated.

Topics: CREOG & APGO Annual Meeting, 2012, Resident, Patient Care, GME, Simulation, Gynecologic Oncology, Minimally Invasive Surgery, Reproductive Endocrinology & Infertility, Female Pelvic Medicine & Reconstructive Surgery,

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Pursuit of Board-Certified Subspecialties in Obstetrics and Gynecology by Graduating Residents, 2001-2010

William F. Rayburn, MD, MBA

Larry C. Gilstrap, MD, Norman F. Gant, MD

Winner 2012 CREOG & APGO Annual Meeting – 3rd Place Poster Presentation

Objective: A lack of growth in the number of residency positions has been compounded by a perception that more graduates wish to subspecialize rather than to function as general obstetrician-gynecologists. The objective of this study was to determine whether there has been an increase in resident graduates pursuing fellowship training in the current board-certified subspecialties.

Methods: This study examined data published annually in the ABOG (American Board of Obstetrics and Gynecology) Diplomate between 2001 and 2011. Annual comparisons were made between the numbers of graduating residents electing to pursue additional training in any of the three board-certified subspecialties. We examined the numbers who took the written examination first-time, became board-certified, and took the maintenance of certification examination in relation to those in general obstetrics and gynecology.
Results: The numbers of resident graduates who pursued and completed fellowship training increased in all three subspecialties with a progressive overall increase from 8.3% to 12.2% (p < .001). The proportion of all graduates who became board-certified in any of the subspecialties each year did not trend linearly (10.8% overall; 4.8% in maternal-fetal medicine, 3.1% in reproductive endocrinology, and 2.9% in gynecologic oncology). Board-certified subspecialists constituted 13.6% of all ACOG Fellows who took their annual maintenance of certification examination.

Conclusion: The previously reported decline in residents entering fellowships in reproductive endocrinology and maternal-fetal medicine has reversed, and the proportion of all graduating residents pursuing fellowship training in the subspecialties increased during the past 10 years. Unless there is a change in fellowship slots, we anticipate that this trend will continue for residents to fill those fellowship positions in those subspecialties. We also anticipate that board-certification in female pelvic medicine and reconstructive surgery will add another 3% into the subspecialty workforce.

Topics: General Ob-Gyn, Maternal-Fetal Medicine, Female Pelvic Medicine & Reconstructive Surgery, Reproductive Endocrinology & Infertility, Gynecologic Oncology, GME, Residency Director, Resident, 2012, CREOG & APGO Annual Meeting,

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Speciality Society Curriculum Affecting CREOG Outcomes

Caron J. , MD
Suzanne Eggers, MD
Background: It is well established that the CREOG inservice exam is designed to identify areas that each individual resident needs to focus on, but also can be used to identify areas of improvement in the residency program itself, which may include adding or modifying curriculum, rotations offered, and didactic topics. Upon review of the CREOG inservice exam scores of the sixteen residents in the Creighton University and Affiliated Hospitals Obstetrics and Gynecology Residency Program, it was noted that in three of the last four years, the program has scored below the national average in the area of Reproductive Endocrinology and Infertility (REI). The residents currently have a two month rotation during the third postgraduate year at an outside hospital. Although it is an excellent rotation, the main focus is infertility, and the contributed faculty have limited time to provide formal didactics. It is not a unique issue as there were several posters at last year's CREOG/APGO meeting that addressed the REI curriculum in other programs. The null hypothesis put forth was that an REI Training Module would not significantly improve CREOG scores from PGY 1 to PGY 2 years and would not improve the program's REI CREOG scores compared to the national average.
Materials and Methods: The residents were required to complete each of the nine ASRM modules from 2010 during the 6 weeks leading up to the CREOG inservice exam. Each resident printed out and turned in the completion certificate after each module. The percentage correct on the REI portion of the CREOG exam was then reviewed looking at 2008 through 2011.
Results: Before the implementation of the modules, no difference was seen in the percent correct of REI scores between the first and second year of the current PGY IVs. After implementation of the modules, the current second year residents showed a significant improvement between their first (no modules) and second year (after modules) REI percent correct scores.(p<0.05). In comparing the three intern classes, 2007 and 2010(without modules) to the intern class of 2011(with modules), the scores increased but not significantly(p=0.178). The overall program percent correct in REI was significantly higher than the program scores averaged over 2008-2010, and for the first time in three years, was higher than the national percent correct.
Conclusion: The ASRM training modules significantly improved the REI CREOG scores in the current second year residents from their first year performance. There was no difference in the performance of two intern classes prior to implementation of the modules and the current intern class that completed the modules. The overall performance of the CU residents improved significantly after completion of the modules compared to those nationally and to the previous two years.

Topics: CREOG & APGO Annual Meeting, 2012, Resident, Residency Director, Residency Coordinator, Competencies Addressed, Patient Care, Medical Knowledge, GME, Assessment, Independent Study, Reproductive Endocrinology & Infertility,

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