How to resolve the current staffing problems in U.S. infertility practices
By Norbert Gleicher, MD, Medical Director and Chief Scientist, at The Center for Human Reproduction in New York City. He can be contacted though The Reproductive Times or directly at either ngleicher@thechr.com or ngleicher@rockefeller.edu.
The market for fertility services is rapidly expanding, mostly due to significant investments by Private Equity in the field. The number of infertility clinics in the U.S. is growing rapidly, and with the first generation of founders of most infertility clinics retiring, the field is experiencing a significant shortage of fertility specialists, embryologists, and even infertility nurses. This article by Norbert Gleicher, MD, one of the last standing Mohicans of first-generation IVF experts, describes the problem and offers solutions.
To a large degree, the consequence of Private Equity entering the fertility field so robustly is that IVF practice has been growing in leaps and bounds, as the number of IVF clinics in almost every U.S. city has significantly increased over the last decade. However, so have the unfilled job openings and, yes, the salaries of almost all positions in the IVF industry.
There simply is not enough staff to hire— not enough REs, not enough embryologists, and/or not enough IVF nurses (whom we call Clinical Coordinators at CHR). As a consequence, most clinics are understaffed, which, of course, has consequences at many different levels. The large Private Equity-owned chains have further aggravated this problem by paying off major hospitals and/or medical schools to take over their fellowship programs, thereby securing the opportunity to pick first among the ridiculously small number of REI fellows who graduate every year.
Under the current fellowship system, that number stands at only approximately 55 REI fellows, who are required to undergo three additional years of training after completing four years of general OB/GYN residency — all, of course, at absurdly low salaries and with many already deeply in debt from student loans incurred during college and medical school.
For our academic establishment, the two-year fellowship— with one year primarily dedicated to clinical training and the second year (supposedly) more geared toward academia and research activities (the emphasis here is on "supposedly," and we will discuss this further below)—was apparently not enough. Several years ago, the members of this establishment, in their infinite wisdom, concluded that the reproductive endocrinology and infertility (REI) fellowship — in the best interest of the field — must be extended to a third, pure-research year.
Why was this additional year required? According to the academic establishment, fellows in two years could not be given enough valuable research time to be seriously initiated into academic research careers, thereby raising the current very inadequate research level of the REI field as a whole. In other words, the academic leadership of the field, in its infinite wisdom, seriously believed that extending the fellowship by a year would convince more fellows to join the academic club, rather than flee into private practice, as a large majority have chosen since the establishment of a formal fellowship in the field.
Most amazingly, the same leadership at least pretended to be surprised that after four years of college, four years of medical school, four years of OB/GYN residency, and three years of REI fellowship (i.e., after 15 years of overall income-negative education), the result was exactly the opposite: Mostly Private Equity-owned IVF clinic networks already signed up fellows in their first year of fellowship. The consequence was that even prominent academic programs often couldn’t recruit enough reproductive endocrinologists (REs) and frequently lost even their own graduates to Private Equity-owned clinic chains.
Nobody should blame the fellows for their decisions. The real culprits behind the mess the field finds itself in are none other than the academic establishment, which now has to face the logical consequences of its own — over decades — very obvious misdirection of the REI field. Like in several other medical specialty areas, the establishment created this mess by purposefully restricting the number of fellowship programs in REI to avoid training too much “competition.” The three-year fellowship idea only further aggravated the problem, bringing it to its current extremes.
Decrying the lack of quality research in the field and using this fact as motivation for a third year of fellowship has little credibility. One must, of course, ask who — ultimately — has been responsible for how sparse good and important research has been in the field. The answer appears obvious: The culprit has been, over decades, the academic establishment itself, as it established, formulated, and executed the training of REI fellows. To be as transparent and factual as possible, it also abused fellowship programs for all this time in pursuit of self-interests rather than educational and scientific goals, often using fellows as a cheap workforce to further their own clinical practice objectives, rather than immersing them in academic pursuits, including serious research activities.
In the days of the two-year fellowships, a large majority of fellows pursued what can only be described as a six-month period of “alibi research.” In the current three-year program, fellows are now "encouraged" to do 12 or even 18 months of such “alibi research,” while, in reality, they are still often covering clinical duties for senior faculty or — because of financial needs — moonlighting elsewhere.
The definition of “alibi research,” also often called “pseudo-research,” is, of course, self-explanatory: It is simply poor-quality research lacking clinical and/or scientific significance. We should not be surprised that this is happening in many — if not most — REI fellowships, because fellows can only be taught serious research by mentors who know and pursue serious research themselves. And how many serious research laboratories or clinical research centers for REI exist these days in academic institutions in the U.S.? Clearly, not too many!
Returning to the main theme of this communication, the general staff shortages in the IVF field do not only involve REs. The shortage also extends to embryologists and specialized nurses. So, what can in vitro fertilization (IVF) clinics do in the face of such very obvious shortages? Looking at the problem practically, there is only one choice: you train your own staff. While training embryologists and nurses has been common practice since the inception of IVF, training your own REs is, of course, a very different story and has become a controversial issue, increasingly discussed in the medical literature.
A recent article in the Journal of Assisted Reproduction and Genetics (JARG) provides a good example. In this commentary, Gerard Letterie, DO, an REI from Pinnacle Fertility in Seattle, WA, addresses the issue of training residency-trained general OB/GYNs as physician extenders to REIs in the IVF field (1). Interestingly, he likens this to the introduction of artificial intelligence (A.I.). He is not the only one linking these two subjects, though from somewhat different viewpoints. Marcelle I. Cedars, MD, one of the REI field’s most accomplished academicians and a strong proponent of three-year fellowships, has done so recently in an article in Fertility and Sterility (2). Not less than 24 prominent authors from different academic institutions pointed out in 2023 how difficult it has become to meet the demand for fertility services, partially because of unfilled positions, and suggested possible options, including the use of physician extenders to REIs (3).
Based on a recommendation by the Society for REI, their manuscript suggested the following and we are quoting:
The field should aggressively explore and implement courses of action to increase the number of qualified, highly trained REI physicians trained annually. We recommend efforts to increase the number of REI fellowships and the size complement of existing fellowships be prioritized where possible. These courses of action include: (a) Increase the number of REI fellowship training programs. (b) Increase the number of fellows trained at current REI fellowship programs. (c) The pros and cons of a 2-year focused clinical fellowship track for fellows interested primarily in ART practice were extensively explored. We do not recommend shortening the REI fellowship to 2 years at this time, because efforts should be focused on increasing the number of fellowship training slots (1a and b).
It is further recommended that the field aggressively implements courses of action to increase the number of and appropriate usage of non-REI providers to increase clinical efficiency under appropriate board-certified REI physician supervision.
Moreover, automating processes through technologic improvements can free providers at all levels to practice at the top of their license.
Except for the insistence on a three-year fellowship, this summary, based on recommendations by the Society for REI, makes a lot of sense. It also allows (under supervision) for the training of general OB/GYNs as extenders of REIs in fertility clinics. We are also aware of clinics that have started using nurse practitioners and physician assistants in such positions. Indeed, we have been informed of clinics allowing them to perform egg retrievals and embryo transfers.
The CHR has experience in training general OB/GYNs in infertility practice, and we know from this experience that an average U.S.-trained OB/GYN can, within one year, easily become a clinically competent provider of fertility services, including IVF (though, of course, excluding advanced surgical training). However, advanced surgical infertility practice has evolved as its own subspecialty.
We have, therefore, become convinced that the current shortage of REIs can be quickly resolved by training general OB/GYNs in properly qualified one-year programs. This approach fully recognizes that it will not include incentives or experience fostering research activities in these candidates. To reach that goal, a second year is required — not as a separate research year, but to allow for a reduced clinical load during both years. This reduction would enable the routine integration of significant research into clinical practice throughout the two years.
Finally, there is one more group of candidates that deserves consideration in alleviating the current acute shortage of REIs, embryologists, and even nurses in the country. This group includes formally trained staff in all three professions from selected foreign countries. REI is a medical specialty that is practiced very similarly to U.S. practice in many countries. Competent REIs from these countries should, therefore, be able to fully integrate into existing IVF programs within a few short months. Many of these candidates may also offer much greater potential for future involvement in research and other academic activities. Individual states with such staff shortages should — obviously under strict criteria — be encouraged to offer quick licensing opportunities for qualified professionals.
Cedars believes that the currently unmet demand for staffing is likely a temporary phenomenon and can be expected to recede (2). However, considering the still much lower utilization of IVF in the U.S. compared to, for example, Europe, we do not subscribe to this opinion. We strongly believe that standard REI fellowships should be restricted to two years as soon as possible, with individuals — of course — given the opportunity for a third year if they, for example, wish to earn an additional degree during that time. In addition, one-year fellowships should be approved at qualified IVF clinics, with qualifications carefully tested upon completion of such a shortened practical clinical fellowship.
References
1. Letterie G. J Assiste Reprod 2024;41(120:3317-3321
2. Cedars MI. Fertil Steril. 2024; 122(2):228-229
3. Hariton et al., Fertil Steril 2023;120(4):755-766