SART Fertility Experts - What is an REI?

Dr. William Gibbons, former President of ASRM and long-time Fellowship Director at Baylor College of Medicine discusses ‘The making of a reproductive endocrinologist and infertility specialist’ with Dr. Daniel Grow. These experts in infertility lead IVF programs, perform reproductive surgery, and perform research to enhance the field of reproductive medicine.

The information and opinions expressed in this podcast do not necessarily reflect those of ASRM and SART. These podcasts are provided as a source of general information and are not a substitute for consultation with a physician. Welcome to SART Fertility Experts, a podcast that brings you discussions on important topics for people trying to build a family.

Our experts are members of SART, the Society for Assisted Reproductive Technology, an organization dedicated to ensuring you receive quality fertility care. So, I'm Dr. Daniel Grow and I am the Division Chief and Fellowship Director at University of Connecticut. And, you know, today we have a very special guest, Dr. William Gibbons, who is not only, was not only my Fellowship Director years ago, but he's had an illustrious career in reproductive medicine.

I'd like to hit just a few of the highlights of his career and then he's going to talk to us today about what makes a reproductive endocrinologist and infertility specialist who they are. So, Dr. Gibbons is a professor of OBGYN, the Director of Reproductive Endocrinology and Infertility at the Baylor College of Medicine. He's the Fellowship Director there.

He's a former department chair and he was an early leader in the field of in vitro fertilization. In fact, during his time at USC, he was, developed the second IVF program in the United States. And then, as chair at Eastern Virginia Medical School, set up one of the first PGD programs in the entire world to, you know, to prevent genetic disease.

He's the past president of the American Society of Reproductive Medicine and an Associate Editor of Fertility and Sterility. So, it's really fun to reconnect with you, Dr. Gibbons, and welcome. Thanks, Dan.

I'm delighted to be here today. I appreciate the invitation. Thanks.

So, let's start off right off the top. What is, Dr. Gibbons, a reproductive endocrinologist? Okay. So, I could start with how do you become a reproductive endocrinologist? That's it.

So, I think that, that if you count grade school and high school and college, it takes a quarter of a century now to become a reproductive endocrinologist. In fact, my dad asked me if I was ever going to go to work. So, maybe I didn't, because they say if you enjoy what you're doing, it's not work.

Wow, that's powerful. But, but it means then that beyond, beyond college, beyond the four years of medical school, okay, beyond the four years of residency in obstetrics and gynecology, there's another three years of training, of which half of which is devoted to research. And so, I think that if we, so it means that we're trying to be, we're trying to train individuals and be trained in the full breadth of the types of diseases that can be, that can involve both women themselves or couples who are trying to conceive.

And in the training program, as I've indicated, half of it's research. And we think the research is really important for several reasons. One, we have a chance to really work with very talented, you know, PhDs and other researchers in our field.

But secondly, I think it's only important that we learn how to ask questions. We learn how we would answer questions. We actually then learn how to evaluate the literature, okay, so that we can understand what is good science and what is good clinical practice and what isn't, so that we can incorporate that into our patient care.

It's really fascinating to me and a little bit heartwarming, actually, that that you mentioned research first as a way to increase depth of knowledge in our field. I think that, I think that all of us are coming to terms on the process of which we are continuing to be students, okay. And if we stop being students, then actually we feel we're probably not offering our patients the best care that they can obtain.

And so we think the research helps us understand that. It may be that many of us may not go, you know, may not go on to do a lot of research, but we, but the fact that we know how to do it and how to interpret it is really important. And the pace of change of the technological changes is increasing rapidly, and so it promotes in each of us the ability to keep up with those changes.

Well, I think that we have, we have essentially, to quote Mason Andrews, the chair at EVMS before I, before I joined the department, is, it's important that we've regularized this process, that's his term, and the fact that, you know, that, and all, and actually all OBGYNs do this, but specifically we have a continuing education program that requires us to review the literature, to be able to evaluate certain manuscripts that are important, and we have to pass a test of that. So, we have regularized the process of which we are trying to maintain our knowledge base in this very complex and increasingly complex area. So, thank you.

We're going to get back to that a little bit more later, I think, but let's, you know, for our audience, many of the patients out there listening to this are wondering what kind of problems does a reproductive endocrine physician treat? Well, we're obviously delighted to help couples who are trying to conceive, and it may be that their issues are that they're not ovulating. It may be that there's mild or even more severe male factor. You know, it could, it could be that they have pelvic adhesions or endometriosis or anatomic things with the uterus of which the uterine, the uterus may be congenitally malformed.

It may have, there may be developing issues such as structural abnormalities within the inside of the uterus such as polyps. It could be fibroids. But also, we also help, we help women who are not ready or not attempting to conceive, and this could be women that are amenorrheic.

They've stopped having periods. So, we try to determine what are the issues that disrupt the system by which the brain tells the pituitary to tell the ovaries to tell the uterus how to do the function normally. And so, we will look at alterations in ovarian function, alterations of adrenal and thyroid function.

Well, we can evaluate the patient who has hirsutism, and we may treat them for their polycystic ovary disease. We may treat them, because many times polycystic ovary disease is just a very, very, very, very, very, very mild form of diabetes. And so, we will treat the insulin resistance.

And so, but this is not, okay, but this does not end, you know, with the middle reproductive years. It's very important to us that we looked at the end of reproductive life, and we're looking at the people that are menopausal, people that are menopausal, because there are important conditions that women who have a loss of ovarian function have to be treated for, such as increasing risk for cardiovascular disease, such as osteoporosis. So, let me just focus on a piece of what you said first.

And from what I heard is that the thing that, the disease that reproductive endocrinologists treat mostly is infertility, but infertility is complicated. And it can be a whole range of problems from the ovary to the uterus to other hormonal conditions to the shape of the uterus or anomalies, and getting down to identify more precisely the cause of the infertility is a real benefit to couples. Well, I think it is, all right? And the reason I say I think it is, because there are clearly couples that walk in the door, they honestly don't absolutely necessarily are focused first on why they're not getting pregnant.

They just want to get pregnant. And so, we see patients that essentially walk and will come in the door with encyclopedic knowledge, you know, of the reproductive system. And we have others that are just saying, I can't get pregnant.

And so, we need to be able to deal, to be able to communicate with patients to say, well, we think, you know, you have these questions about why you get, why you're not getting pregnant, and these are the reasons that we speak of. But it could be that their communication issues are much simpler. Just help me get pregnant.

How does a reproductive endocrinology fellow learn these skills? How do they learn how to treat the infertility patient? And so, if we look at the, you know, if we look at the reproductive endocrine fellows training, you know, which I've indicated is three years, I think that there are multiple ways, meaning that one of the things they're doing, in some ways, they're almost an apprentice. And so, they're working, you know, you know, at the, you know, at the theoretical feet of individuals who have demonstrated their ability, you know, and their mastery of the type of skills necessary in our field. Secondly, we, you know, we have, and there has to be a certain critical mass to do that.

So, there has to be a sufficient critical mass of the teachers and mentors to try to make sure that we can instill an interest in our fellows. It is, honestly, as I've been involved, when I say this, it sounds silly, but it is, you know, it is almost a sacred task to be able to participate in the career growth of young people. And so, it's taken very seriously.

But, in addition, we have didactics, okay. So, essentially, there's lectures that the fellows provide, there's lectures that we provide at a very multidisciplinary approach to try to introduce patients and trainees into the concept. And, actually, I can't say how thankful I am that couples that come to see us seem to be very willing to participate in the process of which we help them, and the fact that we sometimes have other young people working with us.

So, that was a mouthful. And, it was excellent, actually, in terms of the rigors of the training. You know, I know from talking to many patients and talking to many OBGYN physicians that there's a feeling that the REI physician mostly does in vitro fertilization.

And, in vitro fertilization, you know, has been a tremendous help to the infertile couple. And, is it true that the only folks who really do, who practice reproductive, who practice IVF are REI physicians? Pretty much. I think that, you know, I think that you actually tie to another subject.

I believe that, yes, for the vast majority, maybe more than 95 percent of physicians who are involved in in vitro fertilization have had REI training. There are a few people that have been grandfathered and whatever. But, important to that is one of the things that makes me so proud of the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology.

I mean, while there is federal law mandating that we report our IVF results annually, okay, when I look at what SART has done, SART produces validational clinics. SART allows clinics that are underperforming, you know, they will allow help to try to go in to improve the nature. So, I'm proud.

I don't think there's another professional organization that provides learning, validation, education, and continuing medical education and non-medical education from the full, whether it be nurses, whether it be reproductive biologists, PhDs, etc. So, I'm very proud of what SART does because, to me, it is one of the most involved professional organizations that I know anything about. But we, you know, you've indicated, I just want to touch base on one of the other things you've said, and that is, are we just IVF docs? And so, no.

You know, a lot of us love to operate, okay. And so, basically, the types of procedures that we do, we do, most of it is outpatient. It's minimally invasive.

And so, it could be taking a telescope and looking inside the uterine cavity, you know, through the uterine cervix to diagnose intrauterine adhesions, endometrial polyps, submucosal fibroids, or uterine malformations, such as a septate uterus. But also, we do laparoscopy. At laparoscopy, we treat pelvic adhesions, we treat endometriosis, you know, we remove fibroids.

And so, it is, I think that, you know, as I've said, we're trying to practice the breadth of reproductive surgery. Now, as an aside, it may be that our focus many times gets pointed, pushed more toward assistive reproduction. So, let me push you just a little bit on the surgical concept.

And, you know, in OB-GYN, we have the emergence of a new subspecialty, minimally invasive gynecologic surgery, MIGS. And those folks spend a couple of extra years of training, also post-fellowship induced surgery. Are there conditions for which a reproductive endocrine doc receives more training than the MIGS physicians? That's a great question.

Because I think that we have seen in my hospital that there are more and more cases that are going to the minimally invasive surgeons and less so to reproductive endocrine because they're upstream from some of the referral patterns. But I think that it gets to one of the questions you had discussed with me a few days ago was how do we define the difference between an REI and other OB-GYNs? And I think part of it is focus, okay? Part of it is the fact that we're trying to understand the pathophysiology and we're trying to correct the surgical, you know, through surgery to produce an environment that increases the likelihood of conception. I find that so there's no question that there are types of minimally invasive surgery such as the laparoscopic assisted hysterectomy.

But I think that many of us sort of focus. I would say the difference may be focus that we are trying to focus on specific areas. And so there's probably, well there is.

There's surgical procedures that we think the MIGS people are better at doing. But we feel that there's still an important area for us. And I think it'll be interesting to see, you know, what type of pattern occurs over the next decade.

So the focus of the REI physician, just to reiterate, hysteroscopy and optimization of the uterus for pregnancy. Correct. And that would be, that would be a real significant focus of the REI physician.

Very true. And I think that, and so, and so we then, you know, check our work, okay? Meaning that if we, if there is some type of surgical repair involved, we're then going to follow up to make sure that we're satisfied with that. And then, and that's one of the other things.

We ask about some of the exciting places, you know, that reproductive endocrine and infertility is going. It involves our, our increased interest and knowledge base on what, what can result in implantation. What are the issues involved in development of the uterus? And how do we do that to increase the likelihood that a fertilized egg is going to implant? And so we think in some ways that helps direct our surgery.

So, so that we are looking at the type, how do we produce the best nest, okay, so to speak. So we've covered a lot of grounds, and we've talked about the journey that an individual has to go through after their OBGYN residency to become an REI physician. Is there a certification process to become an REI physician? Can you, if you're a patient, you know, how can you be assured that, that your physician, you know, pass through this training successfully? I love this question, okay.

And that's because, for different reasons, okay. You know, for one, someone who's participated in that process as an examiner, that essentially our, our fellows, as they're completing their training, will take a written exam, okay, and they will obtain a pass or a fail. Now frankly, that's what the vast majority of specialty training programs do.

They give their, they give their trainees an exam at the end of the training phase. But unlike most, okay, there may be only two other specialties that do this. We, we ask, we ask our trainees to come back after they've been in practice for two or three years, and we give them an oral exam.

And so we then have the opportunity to see how well they've learned the techniques. We get to learn to see how they've internalized the process and, and how they're actually practicing medicine. And I'm very proud of that.

And while it's a painful process, you know, for the, for the trainee, it's, it means that we care more and to work very hard to see the person that's out there seeing patients is definitely internalizing the kinds of, in times of treatment structures and, and rationales and logic that we think are going to help, that are going to help patients. Further, okay, I think that, and I, and I sort of, I sort of hinted at this earlier, that there's a maintenance of certification program in which, and which essentially every year you have, you have to take, you know, you're, you're, you're given literature to read, okay, and then you have to pass a test on it. And admittedly, so some of that is taken as regular, such as gynecology, with certain sub-focuses on, on cancer and maternal fetal medicine and REI.

So we, you know, so reproductive endocrinologists have to take and, and go through a specific set of, of questions and articles and exams to try to maintain, maintain their accreditation. So, but I wanted to say, I'm just really proud of the fact that we're actually checking on the quality of our, of our ability of our trainees to practice. And so, and that's a scary thing, but it's a wonderful thing for patients.

You know, it's, this was fun today to, to talk with one of my mentors, but someone who I really respect in the field, to have explain what an REI physician is. And I, and I hope that this is valuable to folks. They stay with us.

Yeah, they do. So anyway, so I appreciate this, this opportunity. Thank you.

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