Section 1: Assisted Reproduction Sub-Fertility and Reproductive Endocrinology Learning outcome: To understand and manage sub-fertility with reference to assisted reproduction techniques Knowledge Criteria Clinical Competency Professional Skills and attitudes Training support Evidence/ Assessment Assisted Reproduction Patient selection Clinical prognostic factors relevant in ART -female age -duration of infertility -ovarian reserve -past reproductive history -pelvic organs abnormalities Preparation of patients for assisted reproduction; hydrosalpinx, fibroids, HIV, Hep B and Hep C screening The place of counselling Assessment of the welfare of the child. Communication consent. The Human Fertilisation Take a history Able to identify the cause of infertility and to discuss the role which ART has in its management Able to discuss the limitations and potential complications of ART, including the risk of genetic disorders after IVF/ICSI Arrange relevant further investigations, where necessary, Repeat semen analyses Urine for retrograde ejaculation Endocrine, including ovarian reserve tests Microbiological Genetic (karyotype, CF screening) Ultrasound/HSG/HyCoSy Able to decide which assisted conception technique to use Be sympathetic to the stress related to infertility Ability to explain treatment options, risks and benefits, and need for onward referral Appropriate reading material NICE guidelines in infertility (www.nice.org.uk) Textbooks Journals Human Fertility, Human Reproduction, Fertility and Sterility (www.rcog.org.uk) HFEA documents www.hfea.gov.uk www.eshre.com Clinics Regularly attend Infertility Exposure to IVF Clinics Embryology lab Ovarian ultrasound sessions Case based reports and discussions (CBD) to assess application of knowledge History and information gathering Explanation and planning of treatment according to cause of infertility and prognostic factors 09/02/2007 1
and Embryology Authority (HFEA) and its role. Natural cycle for ART The place, potential limitations and risks of -IUI and SIUI -IVF -ICSI -gamete donation -embryo donation Arrange appropriate referrals to tertiary centres for assisted conception Able to perform ultrasound monitoring of ovarian stimulation Formal courses BFS/RCOG management of the infertile couple and assisted conception courses Explanation of the risks and benefits of hydrosalpinx treatment prior to assisted conception. Controlled ovarian stimulation -physiology of the hypothalamic-pituitaryovarian axis -nature and role of different gonadotrophins preparations -nature and role of GnRH analogues (agonists and antagonists) -different regimes of stimulation (i.e., long-, short-, ultra shortprotocol) -luteal phase support regimes -monitoring of treatment, including follicle tracking and ovarian steroid measurement -consequences of 09/02/2007 2
treatment, including multiple pregnancy and ovarian hyperstimulation syndrome (OHSS) Oocyte retrieval, including potential complications (e.g., infection, bleeding) Optimal day for transfer of the embryos Role and success of egg freezing and embryo freezing Embryo transfer -various catheters used -use of ultrasound scan The place of preimplantation genetic screening (PGS) and diagnosis (PGD) Early pregnancy diagnosis, and management of complications 09/02/2007 3
Section 2: Andrology Learning outcome: To understand and manage sub-fertility with reference to male factor problems Knowledge Criteria Clinical Competency Professional Skills and attitudes Training support Evidence/ Assessment Andrology Process of spermatogenesis and its control Impact of male factors in the genesis of infertility Varicocele Endocrine disorders Coital dysfunction diagnosis and investigation of ejaculatory failure, impotence, retrograde ejaculation Genital infection Immunological causes Testicular maldescent Chromosomal abnormality Take a history Carry out a physical examination Able to use an orchidometer and assess testicular volume Able to recognise testicular tumour varicocele undescended testicles hypospadias absence of vasa deferens Initiate initial investigations, and interpret results Ability to take urethral swabs Arrange relevant further investigations Repeat semen analyses Urine for retrograde ejaculation Endocrine Microbiological Be sympathetic to the stress related to infertility Ability to explain treatment options, risks and benefits, and need for onward referral Appropriate reading material NICE guidelines in infertility (www.nice.org.uk) Textbooks Journals Human Fertility, Human Reproduction, Journal of Andrology (www.rcog.org.uk) Clinics Regularly attend Infertility Exposure to Urology GUM Endocrinology Clinical genetics Oncology Theatre (surgical sperm retrieval) Exposure to Case based reports and discussions (CBD) to assess application of knowledge History and information gathering Explanation and planning of further management OSATS Examination of the male 09/02/2007 4
Chemotherapy, radiotherapy, toxins (including drug effects) Azoospermia Pre-testicular Testicular Post-testicular Genetic (karyotype, CF screening) Ultrasound Arrange appropriate referrals Urologist Endocrinologist Assisted conception Clinical geneticist Psychosexual counsellor Urology Formal courses BFS/RCOG management of the infertile couple and assisted conception courses Severe oligozoospermia (<5 million per ml.) Idiopathic male infertility The place of advanced sperm function tests The place of assisted conception Sequelae of long term low testosterone levels Association with testicular cancer 09/02/2007 5
Section 3: Endometriosis Learning outcome: To understand and manage sub-fertility with reference to Endometriosis Knowledge Criteria Clinical Competency Professional Skills and attitudes Training support Evidence/ Assessment Endometriosis Pathogenesis and epidemiology of endometriosis Classification of endometriosis Relationship between stages of endometriosis and infertility -defective folliculogenesis - ovulatory dysfunction - distorted pelvic anatomy - altered peritoneal function - autoimmune disorders - impaired implantation Diagnostics for endometriosis - laparoscopy - MRI - TV-ultrasound - immuno-biochemistry Take accurate history Carry out a physical examination, including vaginal-rectal assessment Able to perform diagnostic laparoscopy Able to perform transvaginal ultrasound scan Able to decide when to operate Able to arrange non-invasive investigations (MRI and USS) Able to treat early stage endometriosis (I and II) by laparoscopy Able to perform operative laparoscopy/laparotomy for endometrioma Be sympathetic to the symptoms of endometriosis Be sympathetic to the stress related to infertility Ability to explain diagnostic and treatment options, risks and benefits, and need for onward referral where appropriate Appropriate reading material NICE guidelines in infertility (www.nice.org.uk) Textbooks Journals Human Fertility, Human Reproduction, Fertility and Sterility (www.rcog.org.uk) Regularly attend Gynaecology clinic Infertility clinic Theatre sessions Exposure to Ultrasound session Assisted conception clinic Formal courses BFS/RCOG management of the infertile couple and assisted conception Laparoscopy course Case based reports and discussions (CBD) to assess application of knowledge History and information gathering Explanation and planning of the management of endometriosisassociated infertility OSATS Pelvic examination Diagnostic 09/02/2007 6
Treatment options, advantages and disadvantages of each of the following - expectant management - medical treatment - surgical treatment (laparoscopy and laparotomy) Able to liaise with other specialists (urologist, general surgeon and radiologist) to optimise patient s care and to arrange appropriate referrals to tertiary centres Ultrasound course laparoscopy Transvaginal ultrasound The place of assisted conception in the management of endometriosis-associated infertility 09/02/2007 7
Section 4: Management of Anovulation Learning outcome: To understand and manage sub-fertility with reference to ovulation problems Knowledge Criteria Clinical Competency Professional Skills and attitudes Training support Evidence/ Assessment Anovulation The normal physiology of ovulation Pathophysiology underlying disturbances of ovulation Clinical presentation of ovulatory dysfunction Classify disorders of ovulation on the basis of anatomical sites i.e. hypothalamus, pituitary, ovary and hypothalamic pituitary dysfunction Influence of lifestyle, including diet and weight on anovulation Investigation of anovulation Treatment of anovulation, including risks of multiple Able to take a history, examine and record: Menarche Cycle regularity Hirsutism BMI Galactorrhoea Secondary sex characteristics Chemotherapy/pelvic radiotherapy Able to carry out appropriate investigations: Initial screen such as FSH, LH, anti- Mullerian hormone, prolactin, androgens (testosterone, SHBG, FAI) thyroid function tests; pelvic ultrasound (ovarian volume, antral follicle count). Able to carry out appropriate follow up investigations such as MRI, karyotype etc. Be sympathetic to the difficulties on overcoming lifestyle issues such as obesity. Be sympathetic to psychological impact of hirsutism. Understand the impact of psychiatric and psychological issues on anovulation.. Appropriate reading material NICE guidelines in infertility (www.nice.org.uk) Textbooks Journals Human Fertility, Human Reproduction, Endocrinology, Fertility and Sterility (Journal of Andrology) (www.rcog.org.uk) RCOG guidelines http://www.rcog.org.uk/inde x.asp?pageid=8 Formal courses BFS/RCOG management of the infertile couple and assisted conception Attend infertility clinics and a reproductive endocrine clinic. Case based reports and discussions (CBD) to assess application of knowledge History and information gathering Explanation and planning of the management of anovulation Explanation and planning of the management of conditions associated with anovulation. 09/02/2007 8
pregnancy and ovarian hyperstimulation syndrome Association of other medical conditions with anovulation, such as diabetes with PCO, pituitary tumours with hypogonadotrophic hypogonadism The risks and sequelae of hypo-oestrogenism Able to screen appropriately for associated conditions such as autoimmune factors, diabetes mellitus, visual fields, late onset adrenal hyperplasia. Able to advise appropriately on lifestyle issues. Able to decide on an appropriate management plan, and able to explain the likely chances of pregnancy, live birth, risks and benefits for all the alternatives; specifically antioestrogenic compounds such as clomiphene citrate, laparoscopic ovarian diathermy, gonadotrophin, GnRH analogues (agonists and antagonists), dopamine inhibitors, steroids. Able to appropriately decide on the use of adjuvant therapy such as insulin sensitising agents. Attend ultrasound follicle tracking monitoring sessions. Attend a weight loss clinic Or gain equivalent experience Attend General endocrinology clinic Explanation and planning of the management of OHSS OSATS Assessment of the ovary OSATS Follicle tracking, monitoring of ovarian response to ovulation induction OSATS Early pregnancy scanning to confirm location of the pregnancy and viability. Be able to explain to the patient the conditions causing anovulation, the treatments available, with their risks and benefits, including the alternatives. Able to appropriately monitor treatment in order to assess effectiveness and minimise the risk 09/02/2007 9
of multiple pregnancy. Able to give appropriate advice for the management of the condition or its medication in pregnancy, such as the risk of developing gestational diabetes in patients with PCO. Able to identify and manage OHSS. 09/02/2007 10
Section 5: Psychological Aspects of Infertility Learning outcome: To understand and manage sub-fertility with reference to psychological aspects Knowledge Criteria Clinical Competency Professional Skills and attitudes Training support Psychological aspects Evidence/ Assessment Psychological factors in female infertility (i.e., amenorrhoea) Psychological factors in male infertility (i.e., erectile dysfunction) Stress associated with assisted conception treatment Arrange appropriate referral to Counsellors Psychosexual medicine Social services for adoption Local independent adoption societies Ability to explain diagnostic and treatment options, risks and benefits, and need for onward referral where appropriate Be sympathetic to the stress related to infertility, marital disharmony, and difficulties in having intercourse Knowledge of and ability to discuss the role and value of self help groups and community networks of support Appropriate reading material Textbooks Journals Human Fertility, Human Reproduction, (www.bica.net) (www.infertilitynetworkuk.c om) Case based reports and discussions (CBD) to assess application of knowledge History and information gathering Effects of infertility upon the family Regularly attend Infertility clinics The place of counselling in the management of the infertile couple. Exposure to Psychosexual medicine clinics Local facilities for counselling Formal courses BFS/RCOG management of the infertile couple and assisted conception Local facilities for adoption Development of and implementation of multiagency care pathways 09/02/2007 11
Section 6: Tubal Factor Infertility Learning outcome: To understand and manage sub-fertility with reference to tubal factors Knowledge Criteria Clinical Competency Professional Skills and attitudes Tubal factor infertility Aetiology of tubal factor infertility infection, surgery, endometriosis, congenital abnormalities Diagnostic techniques available for assessing tubal disease Pathological features of acute and chronic inflammation associated with tubal factor infertility Classification of tubal disease relevant to natural and therapeutic prognosis Screening of high risk groups Prognostic factors Able to take a careful history and examination Able to decide which diagnostic technique to use. Able to carry out the following procedures: Hysterosalpingography HyCoSy Pelvic scan hysterosonography laparoscopy Able to decide when to operate Management of proximal tubal disease role of selective salpingography and tubal catheterisation Management of distal tubal disease able to carry out salpingectomy, adhesiolysis and salpingostomy by Be sympathetic to the stress related to infertility Be aware of possible guilt feelings if previous infection Ability to explain diagnostic and treatment options, risks and benefits, and need for onward referral where appropriate Training support Appropriate reading material NICE guidelines in infertility (www.nice.org.uk) Textbooks Journals Human Fertility, Human Reproduction, Fertility and Sterility (www.rcog.org.uk) Attend Infertility clinic HSG/HyCoSy sessions Pelvic ultrasound sessions Theatre sessions (with interest in infertility) Exposure to GUM clinic Assisted conception clinic Formal courses BFS/RCOG management of the infertile couple and Evidence/ Assessment Case based reports and discussions (CBD) to assess application of knowledge History and information gathering Explanation and planning of the management of proximal tubal disease and distal tubal disease OSATS Diagnostic laparoscopy Hysterosalpingo graphy or 09/02/2007 12
relevant in decisions for surgery Excision or occlusion of hydrosalpinges prior to IVF laparoscopy or laparotomy The place of reversal of sterilisation assisted conception HyCoSy Adhesiolysis Salpingostomy Knowledge of reversal of sterilisation patients at risk, pregnancy rates The place of assisted conception in tubal factor infertility 09/02/2007 13
Section 7: Unexplained Infertility Learning outcome: To understand and manage sub-fertility with reference to unexplained infertility Knowledge Criteria Clinical Competency Professional Skills and attitudes Training support Evidence/ Assessment Unexplained infertility Understand the nature of the diagnosis (diagnosis of exclusion). Understand other putative causes such as subtle ovulation defects, cervical mucus hostility, endometriosis, subclinical pregnancy loss, occult infection, sperm dysfunction, immunological causes and psychological factors. Understand what investigations could be carried out for these causes, such as post-coital tests, follicle tracking, laparoscopy, immunological screening. Understand the scientific basis for the Able to decide when it is appropriate to consider a working diagnosis of unexplained infertility. Able to explain to the patient the other putative causes for infertility, and the rationale for not investigating for them. Able to explain to the patient the chances of conception naturally and with the different treatment options. Able to devise a plan of care with the different treatment options, and be able to explain the risks, benefits and alternatives. Able to decide when to move on to the alternative treatments. * multi agency stuff (check other module) Be sympathetic to the psychological impact of not identifying a specific cause for the infertility. Provide support for the couple if expectant treatment is the appropriate way forward. Appropriate reading material NICE guidelines in infertility (www.nice.org.uk) Textbooks Journals Human Fertility, Human Reproduction, Fertility and Sterility (www.rcog.org.uk) RCOG guidelines http://www.rcog.org.uk/inde x.asp?pageid=8 Courses BFS/RCOG management of the infertile couple and assisted conception Attend infertility clinics and a reproductive endocrine clinic. Case based reports and discussions (CBD) to assess application of knowledge History and information gathering Explanation and planning of the management of unexplained infertility 09/02/2007 14
investigations Understand the epidemiology and natural history including prognosis for unexplained infertility. Understand the different types of empirical treatment, including clomiphene, intrauterine insemination, superovulation and in vitro fertilisation. 09/02/2007 15
Section 8: Uterine Factor Infertility Learning outcome: To understand and manage sub-fertility with reference to uterine factors Knowledge Criteria Clinical Competency Professional Skills and attitudes Training support Evidence/ Assessment Uterine factor infertility ( intra-uterine adhesions, fibroids, polyps, congenital abnormalities) Aetiology of uterine factor infertility infection, surgery, tumours, congenital abnormalities Diagnostic techniques available for assessing uterine disease Classification of uterine disease relevant to natural and therapeutic prognosis Prognostic factors relevant in decisions for surgery The place of adhesiolysis in the treatment of intrauterine adhesions Able to perform standard transvaginal ultrasound scan to assess the uterus Able to carry out laparoscopy, HSG, hysteroscopy, hysterosonography Know when to request an MRI. Be able to interpret the result Recognise and know how to do a uterine septum and uterine adhesions Know to decide when to treat fibroids and refer appropriately Know when a hysteroscopic myomectomy is appropriate and refer appropriately Know when to recommend a myomectomy by laparotomy and have performed under supervision Be sympathetic to the stress related to infertility Ability to explain treatment options, risks and benefits, and need for onward referral where appropriate Appropriate reading material NICE guidelines in infertility (www.nice.org.uk) Textbooks Journals Human Fertility, Human Reproduction, Fertility and Sterility (www.rcog.org.uk) Regularly attend Infertility clinic HSG/HyCoSy sessions Pelvic ultrasound sessions Theatre sessions (with interest in infertility) Formal courses BFS/RCOG management of the infertile couple and assisted conception Ultrasound course Case based reports and discussions (CBD) to assess application of knowledge History and information gathering Explanation and planning of the management of uterine disease OSATS Diagnostic hysteroscopy TV-USS Hysterosalpingo graphy Sonohysterogra m 09/02/2007 16
Treatment options for uterine fibroids Myomectomy Hysteroscopic division of uterine septum Hysteroscopic division of intrauterine adhesions Hysteroscopic myomectomy 09/02/2007 17
SECTION 1 TOPIC : Assisted Reproduction Skill Competence Level Observation Direct Supervision Independent Practice Date Signature Date Signature Date Signature Take a full history from both partners Able to identify the cause of infertility Discuss the role of ART in lay term with the patient Discuss pros and cons of ART, and what an ART programme entails Discuss the limitations and success of ART Discuss the place of PGS/PGD Able to organise the necessary investigations prior to referral for ART Recommend the most appropriate assisted conception technique based on the results of the investigations Able to perform transvaginal ultrasound scan for antral follicle count and monitoring of ovarian stimulation Diagnose and manage OHSS Familiar with the role of HFEA and its current Code of Practice 09/02/2007 18
Training Courses or sessions Title Signature of educational supervisor Date Authorisation of Signatures please print your name and sign below Name (please print) Signature 09/02/2007 19
SECTION 2 TOPIC : Andrology Skill Competence Level Observation Direct Supervision Independent Practice Date Signature Date Signature Date Signature Take accurate history Perform physical examination Assess male reproductive system (testis, epididymis, vas deferens) Recognise varicocele Arrange relevant investigations (semen analysis, karyotype, CF screening, biochemical tests, testicular biopsy, ultrasound) Take urethral swabs Interpret result of semen analysis Arrange appropriate referrals (urologist, geneticist, counsellor, ART) Discuss treatment options Observe surgical sperm retrieval (Observe vasectomy reversal) 09/02/2007 20
Training Courses or sessions Title Signature of educational supervisor Date Authorisation of Signatures please print your name and sign below Name (please print) Signature 09/02/2007 21
SECTION 3 TOPIC : Endometriosis Skill Competence Level Observation Direct Supervision Independent Practice Date Signature Date Signature Date Signature Take a history and ask relevant questions Perform physical examination, including vagino-rectal assessment Diagnose an endometrioma on TV-USS Arrange non-invasive diagnostic tests (MRI and TV-USS) Interpret results of investigations Decide when to operate Able to perform diagnostic laparoscopy Able to treat early stage endometriosis Able to treat endometrioma by laparoscopy or laparotomy Arrange referral to other specialists when appropriate (e.g. pain clinic, surgeons) 09/02/2007 22
Training Courses or sessions Title Signature of educational supervisor Date Authorisation of Signatures please print your name and sign below Name (please print) Signature 09/02/2007 23
SECTION 4 TOPIC : Management of anovulation Skill Competence Level Observation Direct Supervision Independent Practice Date Signature Date Signature Date Signature Take a history and ask relevant questions Perform physical examination with particular emphasis to secondary sex characteristics Discuss with the patient the possible cause of anovulation and the impact of fertility Able to arrange appropriate endocrine investigations, including a baseline hormone profile, PRL, TFTs, androgens Able to organise and review the results of CT/MRI scan, pelvic/abdominal ultrasound, HSG Able to investigate for autoimmune, infective and genetic causes Advise the patient on lifestyle factors Able to formulate an appropriate management plan Able to liaise with other specialists Able to explain pros and cons of ovulation induction, including the risk of multiple pregnancy, link with ovarian cancer Familiar with the following treatment 09/02/2007 24
strategies: anti-oestrogens, anti-androgens, gonadotrophins, LOD, dopamine agonists, steroids, insulin sensitisers, glitazones, in vitro fertilisation Training Courses or sessions Title Signature of educational supervisor Date Authorisation of Signatures please print your name and sign below Name (please print) Signature 09/02/2007 25
SECTION 5 TOPIC : Psychological aspects of infertility Skill Competence Level Observation Direct Supervision Independent Practice Date Signature Date Signature Date Signature Take history Organise appropriate referrals Explain the need for diagnostic tests Discuss therapeutic options Breaking bad news Explain the risks and benefits of treatment Direct patient to information sites and patient support groups 09/02/2007 26
Training Courses or sessions Title Signature of educational supervisor Date Authorisation of Signatures please print your name and sign below Name (please print) Signature 09/02/2007 27
SECTION 6 TOPIC : Tubal factor infertility Skill Competence Level Observation Direct Supervision Independent Practice Date Signature Date Signature Date Signature Take a history and ask relevant questions Decide which diagnostic test to request Able to perform transvaginal ultrasound Able to perform HyCoSy or able to perform HSG Able to perform saline sonohysterography Able to perform laparoscopy + Dye test Decide when to operate Able to carry out laparoscopic salpingectomy/salpingostomy Able to carry out adhesiolysis Discuss with the patient the place of reversal of sterilisation Discuss the impact of hydrosalpinx on natural fertility and assisted conception, including the role of salpingectomy Discuss the impact of proximal tubal disease 09/02/2007 28
on natural fertility, and the role of selective salpingography Observe selective salpingography or hysteroscopic tubal catheterisation Training Courses or sessions Title Signature of educational supervisor Date Authorisation of Signatures please print your name and sign below Name (please print) Signature 09/02/2007 29
SECTION 7 TOPIC : Unexplained infertility Skill Competence Level Observation Direct Supervision Independent Practice Date Signature Date Signature Date Signature Discuss with patient(s) all possible causes of infertility Decide when to organise a fertility work-up Able to explain the patient(s) in lay term the result of investigations Able to inform the couple of the chances of natural conception Discuss pros and cons of the different therapeutic options Decide when to proceed with therapeutic options Able to decide the time of assisted conception 09/02/2007 30
Training Courses or sessions Title Signature of educational supervisor Date Authorisation of Signatures please print your name and sign below Name (please print) Signature 09/02/2007 31
SECTION 8 TOPIC : Uterine factor infertility Skill Competence Level Observation Direct Supervision Independent Practice Date Signature Date Signature Date Signature Take a history and ask relevant questions Able to perform transvaginal ultrasound and saline hysterosonography to assess the uterus Able to perform laparoscopy and hysteroscopy Able to arrange other tests (HSG, MRI) Decide when to operate Able to carry out hysteroscopic division of uterine septum and intra-uterine adhesions Able to carry out hysteroscopic resection of fibroids Able to carry out myomectomy by laparotomy 09/02/2007 32
Training Courses or sessions Title Signature of educational supervisor Date Authorisation of Signatures please print your name and sign below Name (please print) Signature Completion of Module I confirm that all components of the module have been successfully completed Date Name of Educational Superviser Signature of Educational Superviser 09/02/2007 33