Which obstetrics-gynecology residency programs are training future reproductive endocrinology and infertility fellows? An observational study

Abstract

Objective

To identify where reproductive endocrinology and infertility (REI) fellows trained for residency.

Design

Observational, cross-sectional study.

Setting

Not applicable.

Subject(s)

Reproductive endocrinology and infertility fellows.

Intervention(s)

Not applicable.

Main Outcome Measure(s)

Percentage of fellows who completed residency training at an institution with an REI fellowship program.

Result(s)

A total of 289 fellows were identified among the graduating fellowship classes from 2023–2027. Of those fellows, 69.9% completed residency at an institution that had an associated REI fellowship program, and 19.7% remained at the same institution for residency and fellowship. In the last 5 years, 34.4% of obstetrics and gynecology residency programs have had at least 1 resident enter REI fellowship.

Conclusion(s)

Most matriculated REI fellow physicians train at residency programs that have an associated REI fellowship program.

Obtaining a fellowship position in reproductive endocrinology and infertility (REI) is highly competitive. The REI match rate for the 2023 appointment year was 61.5%, considerably lower than the mean fellowship match rate of 83% for the more than 70 subspecialty fellowships participating in the National Resident Matching Program (NRMP) match (1). The number of obstetrics and gynecology (OBGYN) residents applying for fellowship continues to increase (2, 3). In 2020, approximately 1 in 4 OBGYN graduates entered fellowship (4). Although other OBGYN fellowships added many new training programs, the number of REI fellowship programs has remained similar in recent years (5). As the unmet demand for fertility services grows, more data are needed to recruit and guide prospective applicants (6, 7). Previous studies have suggested that the reputation of residency training programs, board scores, research experience, and interview performance are integral to a successful match (8, 9, 10, 11). Differences in residency training programs can also influence residents' interest in pursuing fellowship training. A survey of 236 OBGYN residents found that those attending a residency with more gynecology oncology (GynOnc) faculty members and those attending programs associated with a GynOnc fellowship were significantly more likely to pursue GynOnc fellowship (P<.01) (12). A study exploring characteristics of successful applicants to pediatric surgery fellowship found that successful applicants were more likely to train at residency programs with a pediatric surgery fellowship (64% vs. 28%) (13). The current study aimed to identify the residency institutions of current REI fellows and determine the percentage of fellows who trained at a residency program with a fellowship.

Materials and methods

All data were collected from publicly accessible websites. This study was deemed exempt from the University of Southern California Institutional Review Board. A list of 302 OBGYN residency programs and 54 REI fellowship programs was obtained from the Accreditation Council for Graduate Medical Education (ACGME) website (www.acgme.org) (14). If a fellowship program was listed as active for at least 1 year from 2016–2023, the associated residency program was included in the cohort of residency programs classified as having an REI fellowship. Fellows graduating from 2023–2027 were included in the study. Fellows and their fellowship training institution were identified through the annual match list published by the Society for Reproductive Endocrinology and Infertility (SREI). The website of each REI fellowship and OBGYN residency program were reviewed to determine the residency institution for each fellow. An additional 5 fellows not included on the SREI list were identified through reviewing program websites. When data were not located using these sources, an online search engine was used. The fellow’s name and a combination of the terms “Dr.,” “OBGYN,” “resident,” “REI,” and “fellow” were used in the search engine. Fellows were included in the study regardless of when they graduated from residency. Two study team members (Z.S.A. and A.D.M.) independently collected data and compared results for correctness. Statistical analysis consisted of descriptive statistics for numerical data.

Results

There were 289 fellows identified among the 5 classes included in the study. Of these fellows, 69.9% (n = 202/289) completed residency at an institution with an associated REI fellowship program. Over the last 5 years, this ranged between 67.7% and 72.7% of fellows per year (Table 1). Nearly one fifth (19.7%) of trainees remained at the same institution for residency and fellowship. Of the 30.1% (n = 87/289) of fellows who completed residency training at an institution without a fellowship program, a majority (62%, n = 54/87) trained at the same 21 residency programs. Seven of the residency programs without an associated fellowship had 3 or more residents match into REI fellowship over the previous 5 years. A total of 54 programs without a fellowship had at least 1 resident enter REI fellowship over the last 5 years. That includes 2 non-ACGME Canadian residency programs. Additionally, there are 2 programs included that are no longer active training programs. In the last 5 years, only 34.4% (n = 104/302) of current ACGME OBGYN residency programs have had a resident enter REI fellowship.

Table 1.

Fellows from a residency program associated with a reproductive endocrinology and infertility fellowship.

Fellowship graduation year	Percentage of fellows from residency associated with fellowship (n)	Total fellows per year
Class of 2023	69.1% (n = 38)	55
Class of 2024	72.1% (n = 44)	61
Class of 2025	67.9% (n = 38)	56
Class of 2026	72.7% (n = 40)	55
Class of 2027	67.7% (n = 42)	62
Total	69.9% (n = 202)	289

Discussion

Over the last 5 years, most fellows (n = 202/289) completed residency training at an institution associated with an REI fellowship program. Given the increasing competitiveness of fellowships, these data may be helpful to prospective applicants. Medical students applying to OBGYN residency report that the opportunity for future fellowship is a high priority when selecting a residency program (15). A comparison of matched and unmatched OBGYN fellowship applicants found that those who had completed residency training somewhere with an in-house fellowship were more likely to match than those who completed residency at a program that did not have it. This finding was significant across all OBGYN specialties (16). The selection of internal candidates, limited subspecialty exposure, and fewer opportunities for research and mentorship may contribute to these findings.

Accepting internal candidates may explain some of the study findings because our data suggest that 19.7% of REI fellows remain at the same institution for residency and fellowship training. We noted a difference in the number of fellowship positions offered according to the NRMP data and the number of incoming fellows included on the annual match list from SREI. The SREI list consistently had more fellows listed than the NRMP for the fellowship graduation years included in this study. This discrepancy could be explained by fellowship programs selecting internal candidates outside the official match process. In 2020, the largest difference between NRMP and SREI-reported positions (n = 19) occurred, and more fellows (n = 17) also remained at the same institution for residency and fellowship that year (1). A higher number of internal candidates selected that year may be the consequence of application changes associated with the coronavirus disease 2019 pandemic, such as transitioning to a virtual interview process. Fellowship programs may have felt that matching internal candidates provided more stability and less risk. Unmatched applicants and programs may also explain some of the differences between the number of fellows listed on the NRMP and SREI lists. After excluding the fellows who completed residency and fellowship at the same institution (n = 57), we still found that most REI fellows (62.5%, n = 145/232) completed residency training at a program associated with a fellowship program.

Most residency programs (65.6%) did not have a graduate match into REI fellowship over the last 5 years. This may be partly because of limited exposure to the subspecialty. Previous studies have suggested that most OBGYN residents lack knowledge regarding REI-related subject matter (17, 18). Residents report frequently being pulled to cover other services and being encouraged or required to take a vacation during their REI rotation (18).

Geographic barriers significantly limit access to fertility care. In a 2017 analysis, Harris et al. (19) explored the number of assisted reproductive technology clinics within a given geographic area. They used US Census core-based statistical areas to define geographic regions. These are defined as an urban center and the surrounding commuting areas, linking socially and economically similar areas. The study found that nearly 30% of US women do not live near an assisted reproductive technology clinic (19). The unequal distribution of REI fellowship locations has also been reported. Diego et al. (20) found a higher density of REI clinics in the Northeast and a lower density in the Midwest or West. Additionally, REI clinics and physicians are more likely to be in urban areas, states with higher income, and states with higher rates of population with insurance. Fellowship programs follow a similar geographic pattern to fertility clinics, further exacerbating the geographic differences in access to care (21). Previous investigators have suggested adding additional fellowship programs and positions, focusing on locations most impacted by the geographic disparities (20, 22). This could have important implications for increasing access to fertility-related care.

A strength of this study is the inclusion of REI fellows over the previous 5 match cycles, representing current match patterns. In the post–coronavirus disease 2019 match cycles, in which virtual interviews are the norm, this represents an updated view of the importance of residency training location. The limitations of the study include the lack of information about additional application components that influence match success. Our analysis did not include the year that fellows completed residency training. Residency institutions may be less important when there is a significant time gap between the completion of residency and beginning of fellowship. Some fellows may dedicate time to research, additional training in genetics or embryology, or working as a generalist before applying to REI fellowship. Future studies should further explore the association between residency training institutions and a successful REI fellowship match by including more applicant characteristics and comparing the differences between matched and unmatched fellowship applicants.

Conclusions

Most REI fellows complete their residency training at a program affiliated with an REI fellowship. It is important to ensure medical students and residents have adequate exposure to REI during their training and that opportunities such as away rotations or mentorship programs continue to be developed. Recruiting medical students and residents from areas where there are few or no REI clinics or providers may help to develop REI physicians who will return to those locations on completion of fellowship training. This strategy could help to recruit more residents to pursue REI from areas of the county most impacted by geographic barriers limiting access to fertility care.

CRediT Authorship Contribution Statement

Zachary S. Anderson: Conceptualization, Methodology, Formal analysis, Investigation, Data curation, Writing - original draft. Erika P. New: Conceptualization, Methodology, Writing - review & editing, Supervision. Aaron D. Masjedi: Validation, Investigation, Writing - review & editing, Visualization. M. Blake Evans: Methodology, Writing - review & editing, Visualization, Supervision.

Declaration of Interests

Z.S.A. has nothing to disclose. E.P.N. has nothing to disclose. A.D.M. has nothing to disclose. M.B.E. has nothing to disclose.