Definition of unexplained infertility and career choice of obstetrics and gynaecology for medical students

Abstract

In this issue of BJOG, I like to highlight the issues relating to the definition of unexplained infertility and the perception of medical students on a career choice of obstetrics and gynaecology.

The concept of unexplained infertility is relatively simple. It is the diagnosis of infertility when all the other known causes such as lack of ovulation, fallopian tubal damage, inadequate sperm count and function, abnormalities of the uterine cavity as well as gynaecological conditions such as endometriosis and adenomyosis have been excluded. Despite the knowledge of the above extensive list of causes of infertility, Raperport and colleagues reported there is still a wide variation in the criteria used to diagnose this condition (pages 880–897). As usual, the devil lies in the details in the definitions employed in the various published guidelines. In their systematic review, they found that not all guidelines recommend the use of recognised diagnostic tests to diagnose the causes of infertility and different diagnostic criteria were also employed for each of these tests. For example, not all definitions require the use of formal day 21 serum progesterone or mid-cycle luteinising hormone surge to diagnose the presence of ovulation as long as there is a history of a regular menstrual cycle. Nearly 30% of the published articles did not specify any criteria on an adequate semen analysis. There is also disagreement on whether the presence unilateral alone or bilateral tubal patency is required to be present in order to exclude the diagnosis of tubal damage as a cause of infertility.

The heterogeneity in the infertility cases labelled as unexplained results in bias when comparing treatment effects reported from different randomised controlled trials as well as when the data from these trials are pooled in a systematic review. It may also result in the patient being prescribed an inappropriate treatment in some cases such as when the diagnosis of endometriosis was not detected during any empirical ovulation induction or assisted reproductive technology treatment.

The authors from this review have therefore called for a harmonisation of the definition of unexplained infertility in order to improve the quality of future research and management for this condition. This call is also echoed by Tarek El-Toukhy, one of our scientific editors, on page 898. A universally adopted definition will reduce the risk of recruitment bias into clinical trials and hence allow meaningful comparison of treatment strategies. This is akin to the call for the establishment of core outcome sets in order to minimise the risk of ascertainment bias.

It is well-known that undergraduate clinical attachments to the different specialities in medicine may have a profound effect on the subsequent career choice for some medical students. This is certainly the case for me after I have completed my undergraduate obstetrics and gynaecology attachment. For others, this may not be the case and they may not discover their career passion until later on. Therefore, it is important that the speciality understands the drivers that motivate medical students embarking into this career.

Sein and colleagues explored the impact of an obstetrics and gynaecology undergraduate placement on the subsequent career choice of medical students at a London teaching hospital using a mixture of questionnaire and semi-structured focus group methodology (pages 961–968). The questionnaire found that there was an increased proportion of students who looked forward and enjoyed their obstetrics and gynaecology placement but this did not translate to an increase in the interest of these students to consider a career in this speciality after completing their placement. The focus group work identified that dealing with healthy pregnant women who do not have an illness, the enjoyable experience of observing childbirth and the speciality being a mixture of medicine and surgery with hands on experience being the reasons to attract them into embarking a career in the speciality. However, the lack of an adequate work-life balance with intensive, on-site out-of-hours and night working, the high levels of responsibility and stress when working with labouring women as well as the emotional toll when there is a bad outcome are the reasons why they are being put off with the speciality. I suspect that most of these less desired reasons relates to obstetrics rather than gynaecology but leaders of the speciality also have a responsibility to be supportive and to provide continuing mentorship to these aspiring doctors to embark and remain in our speciality. The authors have suggested that encouraging more ‘less to full time’ working may further increase recruitment into the speciality. The working condition in the UK has improved significantly over the last few decades with the introduction of the European Working Time Directive and progress made against bullying and harassment at work but this may not be the case in places elsewhere. On page 969, Weissman provided an excellent analogy with a basic marketing tenet that ‘the customer knows best’ on the need to listen and heed the concerns and aspirations of the ‘customer’ who are the medical students deciding to embark on a medical speciality in this scenario. We should apply the findings from the study by Sein and colleagues to implement initiatives that would satisfy the concerns reported.