Reproductive Endocrinology & Infertility Fellowship Program Description

History

Founded in 1791, the University of Vermont  (UVM), located in Burlington, VT, is a state-supported institution offering a highly integrated academic environment for the Fellowship Training Program in Reproductive Endocrinology & Infertility (REI). The teaching hospital of UVM, the University of Vermont Medical Center (formerly Fletcher Allen Health Care), is a tertiary care medical center that serves both the greater Burlington community as well as a catchment area of 1 million people from Northern Vermont and Upstate New York. This program trains one fellow per year, for a duration of 3 years, and a total of 22 fellows have completed the program since 1984.

Duration: 3 years

Prerequisite Training/Selection Criteria

Candidates for training must have an MD or DO degree and have successfully completed residency training in Obstetrics & Gynecology at an ACGME certified training program that is also approved by the American Board of Obstetrics & Gynecology (ABOG). Selection criteria include outstanding performance during residency, as supported by the letters of recommendation, CREOG exams and passing of the USMLE Steps 1-3 or the COMLEX Parts 1-3 for DO's, and a commitment to a professional career in academic Reproductive Endocrinology & Infertility.

Goals and Objectives for Training

The REI Fellowship Training Program is designed to provide advanced training to fellows to allow them to obtain competency in the specialty of REI with sufficient expertise to act as specialist consultants. This training is provided by both the didactic instruction and direct patient care under the direct supervision of expert faculty in the division of REI. Didactic instruction is provided in all areas of REI as outlined in the specific topic areas required by ABOG. 

Direct patient care is provided in a facility that allows state of the art care of both inpatients and outpatients and in a community with a broad range of medical conditions. Through these activities, the fellowship training program provides the environment and resources to allow trainees to obtain competence in the six areas of Patient Care; Medical Knowledge; Practice Based Learning and Improvement; Interpersonal Communication Skills and Professionalism; Systems-based Practice, and Procedures and Practical Experience, as specified by the ACGME and ABOG. 

In addition, the faculty also provides an environment of inquiry and scholarship that involves research, writing and teaching. Critical to the success of the program is a formal structure for frequent feedback and evaluation of performance. At the completion of training, trainees will be prepared to take their board certification exams in both Ob/Gyn and REI.

Program Certifications: Board Eligibility for the ABOG Board Cerification in REI.

Clinical Reproductive Endocrinology and Basic Infertility Clinical Goals and Learning Objectives

Below are listed the clinical goals for each of the clinics and topics each fellow will be working with over the course of their fellowship. The listed goals are based on the American Board of Obstetrics & Gynecology's “Guide to Learning” and will be assessed according to the competencies of: Patient Care; Medical Knowledge; Practice Based Learning and Improvement; Interpersonal Communication Skills and Professionalism; Systems-based Practice, and Procedures and Practical Experience. 

REI Clinic

  • Evaluate patients with endocrine disorders. Be able to diagnose and work up in a cost effective manner, using evidence based principles, disorders such as pituitary prolactinomas, thyroid diseases, Cushings and other adrenal diseases, polycystic ovarian disease, premature ovarian insufficiency, parathyroid disease and mineral metabolism, galactorrhea and others.
  • Be able to design a management plan for patients after the workup is completed and the diagnosis is made. Communicate this plan to primary care and referring providers. Provide education and support to patients to foster their understanding and ability to manage their chronic diseases.
  • Evaluate patients with infertility. Be able to take a comprehensive history and identify areas of concern for further analysis or work up.
  • Be able to comprehensively work up and manage primary and secondary amenorrhea.
  • Be able to identify patients that might benefit from surgical treatment of their conditions. Be able to effectively counsel patients about the risks and benefits of surgery for fertility. Be able to offer the data from other possible management strategies.
  • Understand the pathophysiology and presentations of endometriosis. Be able to evaluate and manage the range of endometriosis stages. Know the relative merits and indications for various medical management techniques as well as surgical management of endometriosis.
  • Understand the workup for Mullerian anomalies. Be able to formulate and implement a plan of care for girls and women diagnosed with various Mullerian developmental conditions as well as other anatomic conditions involving the reproductive systems.
  • Be able to diagnose and manage climacteric conditions. Be able to counsel women on the options for treatment, and risks, benefits, and follow up for each. Be able to include preventive care in care of the late reproductive aged and premenopausal woman. Provide consultative services for management of care of menopausal women.

Basic Ovulation Induction Service

  • Understand the indications and contraindications for beginning OI in a couple. Use and understand the prescreening process before initiating care. Be able to use ultrasound to monitor response to treatment and know how to modulate care based on response. Effectively communicate this process to the patient to enhance patient satisfaction, understanding and compliance with treatment recommendations.
  • Know the various ways to prepare sperm for IUI and when to use each. Be able to perform an IUI even with moderately difficult cervical and uterine anatomy. Know the indications for not performing IUI. Understand how to interpret and be able to explain semen analysis to patients.
  • Manage clomid and letrozole as ovulation induction agents and begin to manage those cycles with minimal supervision. Begin to manage injectable cycles with close mentoring by an attending.
  • Be able to cancel cycles when appropriate and to communicate with patients in a way that promotes patient involvement with decision making.
  • Know how to determine if a therapy has been used optimally and when to move on to other therapies.

Ultrasound in Reproductive Medicine

  • Perform basic pelvic ultrasounds including all the recommended elements and with appropriate documentation and recording of images.
  • Perform first trimester ultrasounds including all the recommended elements and with appropriate documentation and recording of images.
  • Use Doppler and color imaging appropriately to provide more information when appropriate.
  • Be able to create and optimize three dimensional images for facilitating diagnoses.
  • Be able to perform and interpret saline instillation ultrasounds and HYCOSY.  Be able to determine the limitations of these procedures.
  • Be able to suggest other imaging modalities when gyn ultrasound is not definitive. Know how to read and compare other images such as MRI or CT to ultrasound images.
  • Be able to perform a baseline scan and follow up scans in fertility monitoring.

Hysterosalpingogram

  • Perform and interpret HSGs. Know when to treat with antibiotics and when to defer imaging study.

Male Infertility and Andrology

  • Perform a semen analysis. Understand the reporting systems for SA. Perform a Kruger analysis. Understand the clinical implications of the differences in WHO criteria.
  • Perform history and physicals on infertile males and formulate a workup plan. Be able to counsel on results of the workup and create a management plan.
  • Understand the medical treatments available to men with suboptimal sperm counts
  • Perform IUIs. Know the indications and success rates for IUI therapy based on male diagnosis and SA results.
  • Know the indications and relative risks for ICSI
  • Counsel patients about the relative risks benefits and success rates in varicocoele repair.
  • Know the indications for genetics counseling and further workup of men with abnormal semen analyses.
  • Know the indications and prognosis for epidiymal sperm retrieval verses testicular biopsy and retrieval
  • See and counsel patients for sperm cryopreservation. Understand the principles of sperm cryopreservation and also know how to thaw and use sperm in infertility procedures.

Endocrinology

  • Evaluate patients with diabetes, PCOS, thyroid dysfunction, bone metabolic and parathyroid disorders, adrenal dysfunction and multiendocrine disease.
  • Discuss management in both short and long term for chronic diseases with faculty
  • In conjunction with faculty, design workup and treatment plans for patients with complex endocrine diseases.
  • Perform and read DEXA scans and counsel patients on the implications of their testing and treatment recommendations.

Research Rotation

  • Present research concept to thesis committee for review and internal funding.
  • Perform appropriate experiments for thesis.
  • Present results in “work in progress” meeting with division, quarterly.
  • Analyze and interpret experimental results with appropriate experimental modifications.
  • Develop at least one abstract for a national meeting.
  • Observe directly, practice where appropriate, and read about other experimental techniques common to reproductive research but not used in the thesis.  This includes hormone assays, tissue culture techniques, receptor assays, molecular biological procedures, chromosome analysis, gamete manipulation, embryo culture and cryopreservation.
  • Attend your mentor's group meetings and his interdisciplinary immunology group meetings.
  • Learn about statistical methods for the thesis analysis.
  • Learn how to assess and critically review journal articles with Dr. McGee.
  • Write and submit to an outside funding group at least one research proposal.
  • Maintain appropriate duty hours.

Assisted Reproduction Rotation

  • Learn and apply evidence based screening standards for couples seeking IVF.
  • Provide detailed and appropriate patient education and informed consent to couples that are candidates for IVF procedures.
  • Expand on previous ultrasound experience by becoming proficient in ultrasound use in ART. Provide cavity evaluations, ovarian evaluations, baseline scans and cycle monitoring using ultrasound. Understand the benefits and limitations of information available by sonography.
  • Continue to develop proficiency in early pregnancy monitoring and diagnosing pregnancy location by all available clinical, imaging and biochemical techniques.
  • Use ultrasound to perform ovarian puncture and egg retrievals and embryo transfers.
  • Become familiar with the laboratory techniques of in vitro fertilization, ICSI, embryo culture, cryopreservation and vitrification.  Understand the differences in techniques used with different ages of zygotes and embryos. Understand the differences in oocyte vitrification and embryo vitrification.
  • Understand the role of the embryologist and the physician in the embryo transfer. Become familiar with record keeping and documentation required of both the embryologist and the physician and other providers in an ART practice.
  • Understand and be able to communicate to patients, the decision making process in deciding which embryos, how many and when to perform embryo transfers.
  • Learn the pharmacology and use of all medications used in ART.
  • Manage medications and cycle stimulations with increasing independence as proficiency and understanding are attained.
  • Perform mock transfers, oocyte retrieval and embryo transfers with increasing independence as skills are developed.
  • Counsel patients after failed IVF or FET. Be able to tailor support and recommendations to the patient's/couples' individual circumstance.
  • Review patient care and outcomes and identify areas where improvements can be made.
  • Communicate effectively with the team, take and receive feedback to provide collaborative patient care.

Resources

Teaching Staff

Elizabeth McGee, MD                                
Department/Division: Obstetrics, Gynecology & Reproductive Sciences
Role with Fellows: Division Director, Research Mentor

Jennifer Dundee, MD                                 
Department/Division: Obstetrics, Gynecology & Reproductive Sciences
Role with Fellows: Clinical Faculty

Joseph Findley, MD
Department/Division: Obstetrics, Gynecology & Reproductive Sciences
Role with Fellows: Clinical Faculty

Misty Blanchette Porter, MD                      
Department/Division: Obstetrics, Gynecology & Reproductive Sciences
Role with Fellows: Site Director, IVF Rotation, Didactics Speaker

Ira Bernstein, MD
Department/Division: Obstetrics, Gynecology & Reproductive Sciences
Role with Fellows: Department Chair; Research Mentor

George Osol, PhD
Department/Division: Obstetrics, Gynecology & Reproductive Sciences
Role with Fellows: Research Mentor

Elizabeth Bonney, MD
Department/Division: Obstetrics, Gynecology & Reproductive Sciences
Role with Fellows: Research Mentor

Stephen Brown, MD
Department/Division: Obstetrics, Gynecology & Reproductive Sciences
Role with Fellows: Research Mentor

Cory Teuscher, PhD
Department/Division: Med-Immunobiology
Role with Fellows: Research Mentor

Peter Holoch, MD
Department/Division: Urology
Role with Fellows: Urology Rotation; Didactics speaker

Julie Dumas, PhD
Department/Division: Mental Health
Role with Fellows: Research Mentor; Didactics speaker

Michael Toth, PhD
Department/Division: Molecular Physiology & Biophysics
Role with Fellows: Research Mentor

Gary Stein, PhD
Department/Division: Biochemistry/Vermont Cancer Center
Role with Fellows: Research Mentor - Developmental Biology

Paul J. Zimakas, MD
Department/Division: Pediatric Endocrinology
Role with Fellows: Ped Endo Rotation; Didactics speaker

Joel Schnure, MD ,br> Department/Division: Endocrinology
Role with Fellows: Endocrinology Rotation; Didactics speaker

Facilities

All patient care related activities take place at the University of Vermont Medical Center (UVMC), the teaching hospital of the University of Vermont (UVM).  UVMC is a 450 bed, tertiary care academic teaching hospital that serves the greater Burlington, Vermont community as well as the surrounding communities for a 100-mile radius, including Northern Vermont and New Hampshire and Upstate New York. This catchment area includes approximately 1 million people.  Fellow trainees also participate in both clinical and basic science research.

Clinical and Research Requirements

Clinical

Fellows will participate in a variety of clinical rotations to acquire the specialized knowledge, skills and experience they need to practice REI. They will be exposed to all areas of REI as outlined in the ABOG and ACGME guidelines for training in this discipline. As specified by the ABOG, these clinical rotations include Reproductive Endcorinology, Menopause, Endocrinology, Pediatric Endocrinology, Ultrasound and Infertility.

Research

Ample research time (total of 18 months) is provided for fellows to achieve the key objective of the research experience, which is to present their work at a national meeting and/or have their work published in a peer reviewed journal. Simply publishing a case report is not considered an adequate achievement.

Supervisory and Patient Care Responsibilities

Fellows are directly responsible for patient care on the inpatient and outpatient rotations. All patient care is closely supervised by an attending faculty physician.  Fellow trainees supervise the activities of residents and medical students who are also involved in related patient care rotations.

Didactic components

Required conferences

  • One Clinical Conference per week (Thursday noon conference)
  • One Journal Club per month (Wednesday mornings Divisional, or second Thurdays, Departmental)
  • One Core Curriculum Conference per week (Wednesday mornings)
  • One Ultrasound Conference per month (First Wednesday)

Other conferences

Multidisciplinary Ob/Gyn Conferences
Department of Ob/Gyn Grand Rounds
New England Fertility Society Conferences
National Meetings: SRI, ASRM, SSR, ACOG, Endocrine Society

Evaluation

The process of evaluation and feedback for the Reproductive Endocrinology & Infertility training program is as follows:

  • Trainees will be evaluated each rotation they are on a clinical service by the attending physicians. These evaluations will be based on clinical performance, including inpatient and outpatient clinical care, conference presentations and journal club presentations. This will be an electronic evaluation by individual faculty members. These evaluations will be kept on file in the department as part of their permanent record.
  • Trainees will meet semi-annually with the Program Director to review the evaluations. Fellows will be given a printed composite of the faculty reviews that will be kept on file as part of the permanent record.
  • Trainees will anonymously evaluate the attending staff for each rotation of clinical service. The trainees use an electronic evaluation software system called New Innovations to evaluate the attendings. The Program Director will review these evaluations with the faculty on a semi-annual basis.
  • Trainees will evaluate each rotation using the electronic form in New Innovations. This will be used to evaluate each rotation as to it meeting the written goals and objectives. These will be reviewed semi-annually by the faculty.
  • Trainees will undergo a specific evaluation of research project progress by their faculty mentor. The Program Director will review these evaluations with the trainees on a semi-annual basis. The Program Director will review these evaluations with the faculty on a semi-annual basis. Fellows will present their research progress regularly to the division and annually to the department.
  • The Program Director will provide each fellow with a summative evaluation at the completion of the program. This evaluation will document the fellow's performance during the final period of education, as well as document competency to enter practice without supervision. This process will include the specific degree to which the fellow has achieved the level of performance in each of the 6 ACGME competencies.
  • The entire division will participate in an annual Program Evaluation (“Division Retreat”) at the end of each academic year. During this meeting, the fellow will critique the program with regard to overall quality, with specific attention to each rotation, the curriculum, and the teaching, mentoring and research experiences. Other topics to be reviewed will include faculty evaluation of fellow performance, faculty development and graduate performance.