Response by the authors to the commentary of Drs. Thomas and Segars

 In this issue of the Fertility & Sterility Dialog, Drs. Michael Thomas and James Segars present editorial comments: “Validation of a highly realistic embryo transfer simulator and trainer.” Their remarks are in response to our manuscript published in this issue of Fertility and Sterility entitled “Simulation training for embryo transfer: findings from the American Society for Reproductive Medicine Embryo Transfer Certificate Course.”  We thank them for their thoughtful commentary.

The ASRM Embryo Transfer Simulator and accompanying Embryo Transfer Certificate Course were developed with the goals to address a known, large gap in training of REI fellows for those not allowed to perform live embryo transfers and to enhance the skill and confidence of those fellows who can perform live transfers by utilizing a curriculum-based medical education simulation program with a high-fidelity simulator. The purpose of our manuscript was to analyze, for the first-time, proficiency and confidence building as outcomes of completion of the Embryo Transfer Certificate Course and further validate the benefit of simulation as a viable training modality. 

Drs. Thomas and Segars point out:            

• the gap in training live embryo transfer that continues today,
• the potential challenge to using mock embryo transfers as a substitute for live transfers,
• the demonstration of improved skill and confidence as a result of completion of the ASRM Embryo Transfer Certificate Course, and
• the consideration for requiring the Certificate Course as a part of REI fellowship training,

Drs. Thomas and Segars broch the topic of linking pregnancy rates to various aspects of training.  They site studies that demonstrate that a learning curve exists when live embryo transfer training is compared to pregnancy rates and another retrospective study that suggests there is no such learning curve.  They point out that we did not link acquisition of skill and confidence  building to pregnancy rates. However, with fellows from 50% of programs not being allowed to perform live transfers and those fellows going into practice variably being allowed to perform embryo transfers, it was not possible to track embryo transfer pregnancy rates with the improvement of skills and confidence shown in our report.

Opportunities exist for using the ASRM Embryo Transfer Simulator as a research tool for the understanding of factors associated with improvement in pregnancy rates.  For programs for which fellows perform large numbers of embryo transfers (perhaps even 200 or more), the opportunity exists to perform an RCT, randomizing fellows into one of two groups: fellows who complete the Certificate Course then start performing live ETs vs. fellows who begin to perform live embryo transfers without prior training.  This would address the question of whether the Certificate Course is a substitute for live embryo transfers or an important adjunct to training that includes live transfers. Another possible study would be to determine the role of the force of the embryo plunge at transfer in IVF success.  Similarly, studies could be designed for seasoned practitioners to determine the potential for improvement of embryo transfer pregnancy rates at different times during practice.

We are thrilled to have been able to share the data from the ASRM Embryo Transfer Certificate Course.  We are also excited to announce that the next version of the Embryo Transfer Simulator and Certificate Course is under way.  Included in this update is the addition of a fifth uterus (retroverted), the addition of new/additional patient ultrasound volumes to the first four uteri, the addition of a second embryo transfer catheter, and a new module on the different types of embryo transfer catheters and their use.

Sarah A. Ramaiah, M.S.Ed.

Keith A Ray, B.A.

Richard H. Reindollar, M.D.