TPAL for REI: Developing a standardized nomenclature system for summarizing fertility treatment

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TPAL for REI: Developing a standardized nomenclature system for summarizing fertility treatment

Authors:

Caitlin E Martin MD, MS1, Kelsey Anderson MD1, Kaitlin McCallum MD2,3, Kenan Omurtag MD1 

1Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Washington University in St Louis, 4444 Forest Park, Suite 3100, St Louis, Missouri, USA 63108
2Washington University School of Medicine, 660 S Euclid Ave, St. Louis, MO 63110 

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Introduction

The TPAL (term, preterm, abortus, living) system is universally utilized in obstetrics. Most patient notations in obstetrics and gynecology start with a patient’s name and the “Gs and Ps.” From clinic to clinic and from provider to provider, the patient’s reproductive history is immediately understood. There are more subtle aspects of the history that cannot be elucidated from the nomenclature system, however typically one’s history is easily comprehended. It is unclear from literature review when the TPAL system originated; it was suggested for a point of debate in a letter to the editor in the 1970s in Obstetrics and Gynecology (1). Regardless, the TPAL system pre-dated the development of assisted reproductive technology as well as the electronic medical record (EMR).

As indications for fertility treatments expand and become more commonplace, so will the need to succinctly summarize a patient’s fertility history. As a result, a need has emerged for a nomenclature system to describe a patient’s reproductive treatment burden for better communication across the specialty as well as to referring general OBGYNs. Furthermore, nationally there is a requirement to report the number of cycles, fresh starts, frozen transfers, and more.

Currently, when a patient presents who has done ART cycles elsewhere, the patient gives a history of varying clarity and we click and sift through stacks of records to synthesize an accurate treatment history. A simple, shorthand description of a patient’s treatment history can support a more focused review of a patient’s full ART history. This shorthand could benefit numerous stakeholders including covering physicians, nurses, and billing staff and regulatory agencies. Additionally, researchers can efficiently compare patients with different historical backgrounds. Finally, as EMR implementation evolves, having a standard nomenclature system will help EMR vendors and physician champions build better user interfaces and experiences for quicker access to prior treatment histories.  

We set out to develop two nomenclature systems – one system to describe fertility non-ART cycles and one system to describe ART treatment cycles to fill an unmet need to concisely describe a patient’s fertility history in shorthand, similar to the TPAL system with a patient’s reproductive history.

OShI and C-REX: The nomenclature systems

We developed two novel nomenclature systems and performed a retrospective cohort study in order to evaluate two nomenclature systems. The OShI system characterizes the number of non-ART cycles – ovulation induction/superovulation with or without intrauterine insemination (O), gonadotropin medications with or without intrauterine insemination (Sh for shots), and intrauterine insemination alone (IUI - I). The C-REX system describes the number of cycles (C), egg retrievals (R), embryo transfers - fresh and frozen (E), and cancellations (X).

After development of the nomenclature, we reviewed the charts of 175 patients undergoing fertility treatment at Washington University from 6/2020 to 10/2020 (Washington University IRB # 202111035). For evaluation of OShI (n=75), a patient was excluded if it were the patient’s first non-ART cycle or if the treatment history was unable to be obtained from chart review. Cycles completed prior to a previous pregnancy were also included. Each patient’s chart was reviewed and clinical data were summarized by counting the total number of non-ART cycles. Cycles that used clomiphene citrate or letrozole with gonadotropins were included under Sh. For C-REX (n=100), a separate cohort was examined. Fresh autologous, gestational carrier, and donor oocyte cycles were included. Patients were excluded if records were unavailable from prior IVF cycles.  Each chart was reviewed and data were summarized by counting the total number of IVF cycles.  The cycle cancellation category encompasses a range of instances, such as poor response, premature ovulation, and failed fertilization.

Both nomenclature systems were applicable to our cohort

OShI

The OShI nomenclature system worked well in most clinical scenarios, including those using donor sperm (for example scenarios see Table 1). For example, O12,Sh4I3 indicates that a patient underwent 12 cycles of ovulation induction, 4 injectable gonadotropin cycles, and 3 unmedicated IUI cycles. The system does not work well in capturing details such as when an IUI was changed to timed intercourse. The system also does not distinguish between use of letrozole or clomiphene citrate. 

Table 1: Example patient scenarios using the OShI system.  

Example Patient

Ovulation Induction or Superovulation
(O)

Gonadotropins
(Sh)a

IUI alone

(I)

1

12

4

3

2

8

0

1

3

2

0

5

4

1

1

1

5

5

1

1

aSh abbreviation for shots

C-REX

The C-REX system worked well in most clinical scenarios (for example scenarios see Table 2). For example, C7R3E2,3X0 indicates a patient has had 7 cycles with 3 retrievals, 2 fresh and 3 frozen transfers, and no cancelations. The system is also able to synthesize data from gestational carrier cycles and oocyte donation cycles. The system does not work well describing cycles of same sex male couples or single men pursuing fertility with an oocyte donor and gestational carrier. The system does not distinguish if a cycle had preimplantation genetic testing performed. It is also unclear whether a pregnancy resulted from treatment, and we felt that this limitation was not concerning since pregnancy outcome is the primary function of the TPAL nomenclature.

Table 2: Example patient scenarios using the C-REX system.  

 

Cycle
(C)

Retrievals
(R)

Embryo Transfers
(E)

Cancelations (X)

 

 

 

Fresh
(Fr)

Frozen
(Fz)

 

Autologous oocytes

7

3

2

3

0

Autologous oocytes

8

4

2

3

0

Autologous oocytes

10

7

5

1

1

Gestational carrier

3

0

0

2

0

Directed donor

4

3

0

0

0

 

Integration into clinical practice

We have integrated an abbreviated version of the C-REX system into our clinical practice, where each patient presented for weekly IVF conference has a C and R right alongside the TPAL summary. We are in the process of implementing the complete C-REX into our practice. We anticipate that, similar to becoming familiar with the TPAL terminology, it will take some time for everyone in our practice to understand the abbreviations. Although this is a more succinct snapshot of the IVF burden that the patient has undergone. Similar to the TPAL terminology, this nomenclature cannot provide a comprehensive fertility history and is not a replacement for records review but is meant to be a snapshot. Despite some limitations, OShI and C-REX nomenclature can provide a generalizable fertility history that can improve communication between providers. When discussing patients, providers often ask clarifying questions about a patient’s history. By tabulating a patient’s history in the C-REX and OShI systems, many of these answers would instantly be clear. Although not formally assessed, the authors that reviewed the charts did not find it challenging to implement and were in favor of implementing into daily practice.  Additionally, from a systems and research standpoint, it will make it easier to make comparisons between patients with different treatment history.

There are strengths and weaknesses of our nomenclature systems. They are straightforward and incorporate the most important parts of a patient’s fertility history. If universally adopted, it would also assist in communication about patients and also allow for streamlined comparisons for research purposes. They can be placed just alongside a patient’s TPAL summary. For example: A 40-year-old G0 O3Sh0I0 presents for her next IUI. We know that she has had 3 medicated cycles previously. From reading this, we cannot discern if any of the medical cycles had IUIs. However, we do get a sense that she is early along in her fertility treatment journey and understand what may be best to offer her next if this cycle does not work. A 34-year-old G2P1011 C2R2E2,0X0 presents for follow-up on her last IVF cycle. This gives pertinent information about the patient: she has had one previous successful full-term delivery, she has had two cycles, two fresh embryo transfers, and no cancellations. Unfortunately, one cannot discern everything about her history from her C-REX system. For example, it is not clear whether her pregnancy was a result of fertility treatment or whether she has any embryos cryopreserved. However, the short-hand works to give the reader a brief history of what the patient has undergone to focus the history of the present illness. With the growing use of preimplantation genetic testing, it may also be useful to note if frozen embryo transfers were untested, euploid, or mosaic, such as E0,1U,1E,0M.   However, there is a balance that needs to be achieved – if too much is summarized in the nomenclature, such as adding in the protocol for stimulation of endometrial preparation, it will become too cumbersome. 

Call to action: Championing and implementing nomenclature systems

Adoption of new nomenclatures should follow change management principles that can improve patient experience and safety (2).  Business scholar John Kotter published extensively on how to make transformative changes (3). Using his described framework, we need to take the following steps to lead to adaptation of this system. We would need to collectively recognize that adopting this change into daily routine is important – it will lead to better communication and shorter notes. Such a system would make reporting cycle data to Society for Assisted Reproductive Technology (SART) more efficient.  SART already collects national clinic data; our proposed system, or a variation thereof, could ease data submission and processing. To have this nomenclature at one clinic would have limited value; it would be necessary to have major organizations (key stakeholders) such as SART, the American College of Obstetrician and Gynecologists, and the American Society for Reproductive Medicine encourage the adaptation.  Additionally, there would need to be a group of people, aside from the authors, who take the initiative to adopt and champion this system to reach out to key stakeholders and explore barriers to change. Once identified, these barriers would then need to be addressed. We would also need to set goals for short term wins, such as seeing the use of the system in publications. Once short-term goals are accomplished, momentum will be gained and the change can become lasting and part of our canon.

It is time to adapt a short-hand nomenclature system to classify infertility treatment. The OShI and C-REX nomenclature systems are the first formal entry and can be easily adapted to improve communication between clinicians and also assist in summarizing a patient’s treatment burden during the fertility journey. OShI and C-REX are starting points. We encourage others to adapt this system and assess applicability to other patient cohorts and practices. As the field of reproductive endocrinology and infertility continues to shift to use of EMRs and standardization of systems, the OShI and C-REX nomenclatures have the ability to contribute to and improve upon these shifts.

 References:

  1. Li TS. Letter: Primip and multip. Obstet Gynecol. 1975;46(5):631.
  2. Noble DJ, Lemer C, Stanton E. What has change management in industry got to do with improving patient safety? Postgrad Med J. 2011;87(1027):345-8.
  3. Kotter JP. Leading Change: Why Transformation Efforts Fail. Harvard Business Review. 2007;85(1):96-103.