The geographic impact on successfully matching into reproductive endocrinology and infertility fellowship

With an increasing number of obstetrics and gynecology (Ob/Gyn) residents applying to reproductive endocrinology and infertility (REI) fellowship each year and successful match rates declining to nearly 60% as the field becomes increasingly competitive, applicants and training programs are motivated to determine which factors are most important for matching into REI fellowship (1). The first American Board of Obstetrics and Gynecology REI certification examinations occurred in 1974, and although there were initially few programs, waxing and waning over the following years, there are now generally approximately 50 programs participating in the National Resident Matching Program match, most of which take 1 fellow per year (2). As more fellowship training programs have been created over the past few decades, it has become apparent that completing Ob/Gyn training at an institution with an affiliated REI fellowship program dramatically increases the odds of successfully matching into the field. This may be because of the increased exposure to providers and access to research opportunities and piqued interest by the on-site rotational requirements.

Anderson et al. (3) tested this hypothesis in an observational study examining where REI fellows starting fellowship 2020–2024 completed residency training. Over the past 5 REI fellowship match years, 69.9% of fellows did, indeed, train at an Ob/Gyn program with an affiliated REI fellowship, and nearly 20% of all fellows even stayed at the same program for fellowship where they had trained for residency. There are several reasons why it may be appealing to both applicants and programs to maintain a familiar relationship; however, it is important to consider how this pattern of recruitment may further contribute to the existing geographic disparities of the REI physician shortage (4). Recent research suggests that the Northeast has the most REI physicians per reproductive-age women, whereas the Midwest has the lowest. This trend parallels the geographic distribution of REI fellowship programs with almost one half as many programs in the Midwest as in the Northeast. Inherently selecting fellows from areas rich in REI training may result in worse geographic disparity for patients as well as trainees.

To address the increasing demand for fertility services amid physician shortages, the Society of Reproductive Endocrinology and Infertility has recommended increasing the number of REI fellowship training programs and trainee positions, which could also combat this geographic training advantage (5). It is financially prohibitive for many institutions to create fellowships; however, some states, such as Georgia, have expanded funding for trainees in subspecialties including gynecologic oncology by mandating financial support in state legislature (5). However, securing state support for trainees may be challenging in a field such as REI, given recently increasing political scrutiny as a result of lawsuits such as LePage v. Center for Reproductive Medicine (Alabama Supreme Court ruling, February 2024).

Reproductive endocrinology and infertility is a unique field for a number of reasons. In the age of modern medicine, it is still quite novel with rapid developments and changes in practice each year. To maintain the breadth and depth of this field and cultivate continued growth, we should recognize self-selecting trends for trainees, such as those explored by Anderson et al. (3) to ensure that we are taking action to achieve equitable and inclusive training opportunities for REI providers that may enhance equitable and inclusive patient care. These actions may include lobbying for state legislature for support at academic institutions or expanding fellowship locations to private practice offices capable of providing adequate faculty and training opportunities. The current guidelines and requirements for REI fellowship training have somewhat limited fellowship training to academic-only divisions or academic-private practice collaborations, although a significant amount of fertility care has migrated from academic institutions to private practices (5). The recent reduction in research requirement for REI fellowship from 18 months to 12 months along with observed variability among REI fellowship curricula may support expanding fellowship training to sustainable private practice settings in the future and serve to combat the observed geographic training advantage.

CRediT Authorship Contribution Statement

Megan R. Sax: Conceptualization, Methodology, Writing – review & editing.

Declaration of Interests

M.R.S. has nothing to disclose.