Training clinicians in culturally relevant care: a curriculum to improve knowledge and comfort with the transgender and gender diverse population
Kreines, Fabiana Maria; Quinn, Gwendolyn P; Cardamone, Stefanie; Pi, Guillermo E; Cook, Tiffany; Salas-Humara, Caroline; Fino, Elizabeth; Shaw, Jacquelyn
PURPOSE/OBJECTIVE:To design a replicable simulation curriculum collaboratively with the transgender and gender diverse community to improve clinician knowledge and comfort with providing reproductive care to this population. METHODS:This is a prospective, single arm pre-post analysis of obstetrics and gynecology residents at a single academic institution after completion of a novel simulation curriculum. The primary outcome was the change in resident comfort and knowledge in providing transgender and gender diverse patient care. A thematic analysis of learner and standardized patient free text responses was analyzed for insights on perceived learner experiences. RESULTS:This curriculum was created with iterative feedback from the transgender community and involved only transgender and gender diverse-identified standardized patients. Thirty residents participated, with 22 responding to both the pre-and post-curriculum surveys, and 11 responding to a 6-month post-curriculum survey. There were significant improvements in learner comfort and knowledge after participation that were found to persist at 6Â months. Qualitative analysis demonstrated that this was a positive and powerful learning experience for both residents and standardized patients. CONCLUSIONS:This simulation curriculum may be an effective and impactful tool to increase trainee comfort and knowledge of transgender and gender diverse patient care, which is important given the lack of physician training in the care for these individuals. By building the foundation with resident learners, the ultimate goal is to enhance the pool of clinicians confident and capable of caring for transgender and gender diverse patients, to increase access to care, and to improve health outcomes in this vulnerable population.
Why are Black individuals disproportionately burdened with uterine fibroids and how are we examining this disparity? A systematic review
Charifson, Mia A.; Vieira, Dorice; Shaw, Jacquelyn; Kehoe, Siobhan; Quinn, Gwendolyn P.
Objective: To systematically review and summarize the literaure on nongenetic risk factors that may contribute to the racial disparity in uterine fibroids (UF) that disproportionality impacts Black individuals at 2-3 times the rate of White individuals and how the racial disparity has been studied to date. Evidence Review: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol checklist guided the systematic review process. From January 1 to June 1, 2021, relevant articles were retrieved from PubMed, EMBASE, Web of Science, and Cochrane Library. Multiple investigators screened, assessed, extracted, and critically appraised the data. Results: A total of 44 articles examined the relationship among UFs, race/ethnicity, and nongenetic risk factors, including cardiometabolic features, comorbidities, diet, chemical exposures, vitamin D levels, reproductive characteristics and socioeconomic factors, and life experiences. Most studies reported on the same 3 cohort study populations, and there was inconsistent statistical reporting of the race/ethnicity, risk factors, and UF relationship. Conclusion: Many potential risk factors related to the racial disparity in UF have been studied thus far. There is still little conclusive evidence regarding which risk factors are the greatest contributors to racial disparities in UF. Promising areas of research deserve greater attention and a greater diversity of study populations and analytical methods.
FRAGILE X CARRIERS: IS THERE EXPANSION IN UTILIZATION OF PREIMPLANTATION GENETIC TESTING FOR MONOGENIC DISORDERS (PGT-M)? [Meeting Abstract]
Shaw, J; Besser, A G; Grifo, J A; Blakemore, J K
Objective: Fragile X (FgX) is a recommended part of carrier screening with pre- and full mutations associated with a spectrum of disease including intellectual disability, tremor ataxia syndrome and premature ovarian insufficiency. Risk of expansion is categorized based on number of CGG repeats.1 Testing for AGG interruptions can offer further risk assessment in some cases.1 As these tests become more commonplace, our objective was to determine how often screened patients select PGT-M for FgX.
Material(s) and Method(s): This is a retrospective case series at a single academic fertility center. Electronic medical records were queried to identify patients with a positive carrier screen for FgX from 2008-2022 and those undergoing PGT-M for FgX. Assisted reproductive treatments and outcomes were reviewed. Kruskal Wallis and Chi-square statistical tests were performed (p<0.05 significant).
Result(s): 393 positive FgX reports were identified including 20 prospective oocyte donors. 63% (247/393) had an intermediate (INT) number of CGG repeats (45-54), 34% (133/393) had a premutation (PRE) (55-200 repeats) and 0.8% (3/393) had a full mutation (FUL) (>200 repeats). 61% (238/393) underwent fertility treatment at our center. PRE patients were younger (INT: 36 (17-47) vs PRE: 33 (21-44) vs FUL: 37 (37-39) years (Y), p<0.01). Anti-mullerian hormone levels were similar (INT: 1.9 (0.03-14) vs PRE: 1.5 (0.01-8.7) vs FUL: 3 (0.1-5) ng/mL, p=0.08). Only 37% (49/133) of PRE carriers underwent AGG testing to further risk stratify expansion potential, as did 2% (4/247) of INT. 25% (13/53) had 0 AGGs: 4 declined fertility treatment, 4 cryopreserved oocytes, 5 underwent PGT-M. 12% (49/393) in total underwent PGT-M: 4% INT (2/49), 73% PRE (36/49), 6% FUL (3/49). 27% (13/49) of PGT-M patients underwent AGG testing: 38% (5/13) had 0 AGG, 38% (5/13) had 1 AGG, and 23% (3/13) had 2 AGGs. 8% (4/49) additional patients were offered but declined AGG testing. 18% (9/49) of PGT-M patients had terminated an affected pregnancy prior to PGT-M. 10% (5/49) had documented family members affected or PRE carriers. Patients underwent median 2 retrieval cycles (range 0-5) and 1 embryo transfer cycle (range 0-5). 31% (14/45) of patients with completed treatment did not achieved an autologous euploid unaffected embryo for transfer; two of these patients transferred non-euploid unaffected embryos and 71% (10/14) had AMH <0.8ng/mL. 1 INT and 2 PRE female embryos were also transferred. 46% (13/28) of transfers resulted in a live birth.
Conclusion(s): PGT-M is most commonly used for PRE carriers and with a history of prior affected pregnancy or family member, with varied use of AGG testing. Patients with low ovarian reserve are less likely to achieve an autologous live birth of an unaffected embryo from PGT-M. Impact Statement: FgX premutation carriers do not have uniform uptake of AGG testing or PGT-M and require individualized counseling due to differences in risk assessment and varied assisted reproductive technology outcomes. Support: None REFERENCES:: 1. Monaghan KG, Lyon E, Spector EB; American College of Medical Genetics and Genomics. ACMG Standards and Guidelines for fragile X testing: a revision to the disease-specific supplements to the Standards and Guidelines for Clinical Genetics Laboratories of the American College of Medical Genetics and Genomics. Genet Med. 2013 Jul;15(7):575-86.
A QUALITY IMPROVEMENT PATHWAY (QIP) FOR FERTILITY CARE (FC) IN GENERAL OBSTETRICS AND GYNECOLOGY (GYN) CLINIC AT NEW YORK CITY (NYC)'S LARGEST PUBLIC HOSPITAL [Meeting Abstract]
Parra, C M; Shaw, J; Cascante, S D; DeVore, S; Blakemore, J K
Objective: Infertility affects >100 million people worldwide; improving FC access is essential, especially for low socioeconomic and minority groups. In NYC's public hospital system, patients (pts) are referred to a fellow-led reproductive endocrinology and infertility (REI) clinic that provides consults, work-ups and ultrasound-monitored controlled ovarian hyperstimulation and ovulation induction (OI). REI referrals (REF) are in high demand limiting appointment (appt) availability1 with new pts waiting >5 months. We developed a QIP to identify pts for OI counseling and initiation in GYN clinic.
Material(s) and Method(s): REI fellows screened all REFs, and scheduled eligible pts in GYN. QIP criteria: age <38 years (y); anti-Mullerian hormone (AMH) >2ng/mL; normal prolactin, thyroid function and hemoglobin A1C; no known reproductive issues/comorbidities requiring high risk obstetrics; <3 prior OI cycles. Eligible pts received early follicular letrozole 2.5mg for 5 days (d) in GYN and were then followed in REI's OI program. Non-eligible pts were scheduled in REI. To assess effectiveness, we retrospectively compared all REF outcomes from PRE-(3/1/21-5/31/21) to POST-(9/1/21-11/30/21) QIP as of 2/14/22. A transition period (6/1/21-8/31/21) was excluded. Primary outcome was time from REF to scheduled appt. Secondary outcomes included time from REF to OI prescription/cycle start. Statistics included Mann-Whitney, Chi-square, Fischer's exact and Two-sample t tests (p<0.05 significant).
Result(s): PRE (n=121) and POST (n=102) REFs had similar median ages [36 (interquartile range (IQR): 32-39) PRE vs 35y (IQR: 31-40) POST, p=0.73], ethnic/racial identity [56.2% (68/121) PRE vs 53.9% (55/102) POST Hispanic (p=0.79); 34.7% (42/121) PRE vs 30.4% (31/102) POST Black (p=0.59)], and rates of no prior FC [88.4% (107/121) PRE vs 93.1% (95/102) POST, p=0.15]. QIP identified pts for GYN who were younger [median age 29 (IQR: 27-33) vs 38y (IQR: 33-41), p<0.01], had higher AMHs [median 3.065 (IQR: 2.315-4.883) vs 1.230 ng/mL (IQR: 0.513-3.630), p<0.01], and had fewer comorbidities [100% (19/19) vs 72.5% (50/69), p<0.01] compared to REI. After QIP implementation, median time from REF to scheduled appt decreased from PRE 151 (IQR: 125-173) to POST 98d (IQR: 73-137) (p<0.01). For pts seen in clinic thus far, median time from REF to OI prescription decreased from 150 (IQR: 122-173) to 82d (IQR: 63-119) (p<0.01) and to 1st follicle check from 202 (IQR: 159-221) to 107d (IQR: 98-115) (p<0.04). In the POST cohort, 86.3% (88/102) of REFs had visits scheduled, with 21.6% (19/88) in GYN and 78.4% (69/88) in REI. OI was started at initial visit for 61.5% (8/13) of GYN pts vs 25.8% (8/31) of REI pts (p<0.04). 38.5% (5/13) of GYN pts met criteria for QIP, but were pending >1 blood test, while 51.6% (16/31) of REI pts were pending further work-up.
Conclusion(s): Our QIP expedited FC for all pts by reducing the time from REF to scheduled fertility appt by 35% (median of 53d) and to OI prescription/cycle start by nearly 45% (medians of 68d/95d). Impact Statement: Similar OI pathways could improve access to FC for underserved populations in broader practice settings. REFERENCES: 1 Blakemore JK, Maxwell SM, Hodes-Wertz B, Goldman KN. Access to infertility care in a low-resource setting: bridging the gap through resident and fellow education in a New York City public hospital. J Assist Reprod Genet. 2020 Jul;37(7):1545-1552.
DOES LUTEAL ESTRADIOL PRIMING (E2P) IMPROVE EUPLOIDY IN PREIMPLANTATION GENETIC TESTING FOR ANEUPLOIDY (PGTA) IN VITRO FERTILIZATION (IVF) IN SOCIETY FOR ASSISTED REPRODUCTIVE TECHNOLOGY (SART) AGES? [Meeting Abstract]
Shaw, J; Grifo, J A; Blakemore, J K
Objective: E2P is a technique for IVF protocols in poor responders to reduce cycle cancelation due to elevated FSH as well as increase stimulation response. Yet data is inconsistent on the impact on clinical pregnancy rates.1 We sought to evaluate if E2P increases euploidy rates in IVF with PGTA.
Material(s) and Method(s): This is a retrospective cohort study of IVF cycles with PGTA from 3/2020-12/2021 at a single academic fertility center. E2P cycles were compared to age and AMH matched controls (CON) (1:2 ratio). The primary outcome was number of euploid embryos. Secondary outcomes were cycle start follicle stimulation hormone level (FSH), total gonadotrophin (GND) dose, number oocytes, mature oocytes (MII), fertilization rate (2PN), and number of embryos biopsied (BX). Mann Whitney and Chi-square tests were performed (p<0.05 significant). Data is reported in median (range) and percentages.
Result(s): 337 E2P cycles were compared to 674 CON. There were fewer microdose lupron (MCD) cycles in E2P patients (E2P: 88% antagonist (ANT), 12% MCD vs CON: 76% ANT, 24% MCD, p<0.01). Similar cancelation rates [E2P: 14% (47/337) vs CON: 12% (82/674), p=0.42] and poor blast formation (defined as nothing for biopsy) [E2P: 18% (60/337) vs CON: 15% (103/674), p=0.24] were seen between groups. Number of euploid embryos were similar across all SART age groups except for 38-40 years (y), with fewer euploids in E2P (Table). Cycle start FSH was lower and total GND dose was higher for E2P (p<0.05). Other cycle outcomes were not different.
Conclusion(s): E2P is a viable tool for PGTA freeze all cycles, but does not improve euploidy rate; larger studies are necessary to determine if E2P produces fewer euploids in >38y. Impact Statement: E2P cycles require higher GND dose without increased yield in euploid embryos. [Formula presented] Support: None REFERENCES: 1. Orvieto R. Pretreatment: Does it improve quantity or quality? Fertil Steril. 2022 Apr;117(4):657-663. Epub 2022 Mar 5. PMID:.
Fertility Preservation for Adolescent and Young Adult Transmen: A Case Series and Insights on Oocyte Cryopreservation
Barrett, Francesca; Shaw, Jacquelyn; Blakemore, Jennifer K; Fino, Mary Elizabeth
Background/UNASSIGNED:The opportunity for fertility preservation in adolescent and young adult (AYA) transmen is growing. Many AYA transmen desire future biologic children and are interested in ways to preserve fertility through oocyte cryopreservation prior to full gender affirmation, yet utilization of oocyte cryopreservation remains low. Additionally, standard practice guidelines currently do not exist for the provision of oocyte cryopreservation to AYA transmen. Our objective was to review our experience with oocyte cryopreservation in adolescent and young adult transmen in order to synthesize lessons regarding referral patterns, utilization, and oocyte cryopreservation outcomes as well as best practices to establish treatment guidance. Methods/UNASSIGNED:This is a case series of all AYA transmen (aged 10 to 25 years) who contacted, consulted or underwent oocyte cryopreservation at a single high volume New York City based academic fertility center between 2009 and 2021. Results/UNASSIGNED:Forty-four adolescent and young adult transmen made contact to the fertility center over the study period. Eighty percent (35/44) had a consultation with a Reproductive and Endocrinology specialist, with a median age of 16 years (range 10 to 24 years) at consultation. The majority were testosterone-naive (71%, 25/35), and had not pursued gender affirming surgery (86%, 30/35). Expedited initiation of testosterone remained the most commonly cited goal (86%, 30/35). Fifty-seven percent (20/35) pursued oocyte cryopreservation. Ninety-five percent (19/20) underwent successful transvaginal oocyte aspiration, with a median of 22 oocytes retrieved and 15 mature oocytes cryopreserved. There were no significant adverse events. At time of review, no patient has returned to utilize their cryopreserved oocytes. Conclusions/UNASSIGNED:Oocyte cryopreservation is a safe fertility preservation option in AYA transmen and is an important aspect of providing comprehensive transgender care. Insights from referral patterns, utilization, and oocyte cryopreservation outcomes from a single center's experience with adolescent and young adult transmen can be integrated to identify lessons learned with the goal of providing transparency surrounding the oocyte cryopreservation process, improving the education and comfort of patients and providers with fertility preservation, and easing the decision to pursue an oocyte cryopreservation cycle in parallel to gender-affirmatory care.
Universal SARS-CoV-2 polymerase chain reaction screening and assisted reproductive technology in a coronavirus disease 2019 pandemic epicenter: screening and cycle outcomes from a New York City fertility center
Shaw, Jacquelyn; Tozour, Jessica; Blakemore, Jennifer K; Grifo, James
OBJECTIVE:To evaluate the prevalence of coronavirus disease 2019 (COVID-19) and efficacy of a universal screening program in patients undergoing controlled ovarian stimulation (COS). DESIGN:Single-center retrospective cohort study. SETTING:Academic fertility center in an epicenter of the COVID-19 pandemic. PATIENT(S):All patients undergoing COS from June 17, 2019, to February 28,Â 2021. INTERVENTION(S):Universal COVID-19 screening starting June 17, 2020, with SARS-CoV-2 polymerase chain reaction testing within 5 days of oocyte retrieval, patient-reported symptom screening, and temperature monitoring. MAIN OUTCOMES MEASURE(S):The primary outcome was the number of positive COVID-19 cases in patients undergoing COS cycles. The secondary outcomes were cycle outcomes compared with before COVID-19 COS cycles, adverse outcomes in COVID-canceled cycles, and center-specific COVID-19 detection rates compared with New York City cases. RESULT(S):From June 17, 2020, to February 28, 2021, 1,696 COS cycles were initiated with only seven positive COVID-19 cases for an overall positivity rate of 0.4%. When compared with before COVID cycles from June 17, 2019, to February 28, 2020, the volume of COS cycles were higher, while the overall cycle cancelation rate was lower during COVID-19. Cycle outcomes including oocyte yield and blast utilization rates were unchanged from pre-COVID cycles. Cases of COVID-19, while very low, occurred more frequently during surges in New York City rates. CONCLUSION(S):Assisted reproductive technology can be performed during the COVID-19 pandemic utilizing frequent universal screening and safe practices with low SARS-CoV-2 positivity, low cycle cancelation rates, and positive patient outcomes.
ON THE MOVE: THE IMPACT OF THE COVID-19 PANDEMIC ON MOVEMENT OF CRYOPRESERVED OOCYTES AND EMBRYOS [Meeting Abstract]
Kelly, A G; Roth, L; Shaw, J; McCaffrey, C; Atkinson, A L; Blakemore, J K
OBJECTIVE: COVID-19 has influenced family building, delayed fertility care, and affected people's decisions about where to live.We sought to understand differences in movement of cryopreserved reproductive tissue before and during the pandemic. MATERIALS AND METHODS: This was a retrospective cohort study of patients who transported tissue into or out of a single academic fertility center in New York City (NYC). Tissue transport was compared the year before (PRE, 4/1/2019-3/31/2020) and after (DUR, 4/1/2020-3/31/2021) the height of the COVID-19 pandemic in NYC, an epicenter. The primary outcome was the number of patients transporting tissue DUR compared to PRE. Secondary outcomes were the number of geographic changes, type of tissue, geographic origin/destination, and type of movement (in or out). Statistical analyses were performed using Kolmogorov-Smirnov, Wilcoxon Signed Rank Sum, Chi-Square, and Fisher's Exact tests with p<0.05 considered significant.
RESULT(S): A total of 367 tissue transports were included, with similar rates between cohorts (PRE 46.3% (170/367) vs DUR 53.7% (197/367), p=0.16). The median age at transport was the same (PRE 41 (range 29-54) vs DUR 41 (range 28-54) years, p=0.54). A similar amount of tissue was transported in (PRE 30.0% (51/170) vs DUR 35.0% (69/197)) and out (PRE 70.0% (119/170) vs DUR 65.0% (128/197), p=0.32). Patients were more likely to transport embryos pre-pandemic (37.6% (64/170) oocytes vs 61.8% (105/170) embryos, PRE) and oocytes during COVID-19 (51.8% (102/197) oocytes vs 44.2% (87/197) embryos, DUR) (p<0.01). A subgroup analysis excluding tissue moved for a gestational carrier or donor gametes found a similar number of transports were due to patient geographic relocation (PRE 50.0% (61/122) vs DUR 40.5% (60/148), p=0.12). Examination of geographic origin and destination of tissue PRE vs DUR produced no identifiable trends (p=0.38). Timing of tissue transport varied. The monthly transport rates were relatively even PRE (average 8% per month). However, during the pandemic, there were few transports in the beginning (April-May 2020, 0-1% per month) followed by a peak of transports in June-August 2020 (10-11% per month) and February-March 2021 (11-16% per month) (p<0.01). Transport activities were impacted by closure of clinics and courier service availability.
CONCLUSION(S): The rate of cryopreserved tissue movement did not differ in the year before versus during the pandemic at our center, despite being in a COVID-19 epicenter, although transport activities were concentrated into fewer days. There was peak movement of tissue three months after the pandemic onset and roughly one year from the start of the pandemic. The type of tissue transported shifted to favor oocytes during the pandemic, warranting more investigation in how COVID-19 impacted family building activities. IMPACT STATEMENT: Despite the impact of COVID-19 on reproductive and place of living choices, the pandemic did not affect the amount of cryopreserved tissue that was relocated. However, insight into the increased movement of oocytes and potential impacts on warming outcomes or timelines is necessary
The Role of Gender in Careers in Medicine: a Systematic Review and Thematic Synthesis of Qualitative Literature
Winkel, Abigail Ford; Telzak, Beatrice; Shaw, Jacquelyn; Hollond, Calder; Magro, Juliana; Nicholson, Joseph; Quinn, Gwendolyn
BACKGROUND:Gender disparities exist in the careers of women in medicine. This review explores the qualitative literature to understand how gender influences professional trajectories, and identify opportunities for intervention. METHODS:A systematic review and thematic synthesis included articles obtained from PubMed, Cochrane Central Register of Controlled Trials (Ovid), EMBASE (Ovid), APA PsycInfo (Ovid), and GenderWatch (ProQuest) on June 26 2020, updated on September 10, 2020. Included studies explored specialty choice, leadership roles, practice setting, burnout, promotion, stigma, mentoring, and organizational culture. Studies taking place outside of the USA, using only quantitative data, conducted prior to 2000, or focused on other health professions were excluded. Data were extracted using a standardized extraction tool and assessed for rigor and quality using a 9-item appraisal tool. A three-step process for thematic synthesis was used to generate analytic themes and construct a conceptual model. The study is registered with PROSPERO (CRD42020199999). FINDINGS/RESULTS:Among 1524 studies identified, 64 were eligible for analysis. Five themes contributed to a conceptual model for the influence of gender on women's careers in medicine that resembles a developmental socio-ecological model. Gender influences career development externally through culture which valorizes masculine stereotypes and internally shapes women's integration of personal and professional values. CONCLUSION/CONCLUSIONS:Medical culture and structures are implicitly biased against women. Equitable environments in education, mentoring, hiring, promotion, compensation, and support for work-life integration are needed to address gender disparities in medicine. Explicit efforts to create inclusive institutional cultures and policies are essential to support a diverse workforce.
MYOMECTOMY - DOES ROUTE IMPACT EUPLOID EMBRYO TRANSFER OUTCOMES? [Meeting Abstract]
Pecoriello, Jillian; Shaw, Jacquelyn; Eswar, Christopher; Licciardi, Frederick