The Duke REI fellowship is divided into 18 months of clinical experience and 18 months in the laboratory, which includes some combination of research and IVF laboratory experience. Fellows are are able to gain experience with endocrine and infertility patients.
The first year of fellowship is primarily clinical. Fellows are active in monitoring of ART patients, performing transvaginal oocyte retrievals (TVOR), mock and live embryo transfers and observing andrology/embryology laboratory techniques. They also primarily perform office procedures of intrauterine insemination, hysterosalpingography, saline infusion ultrasound and hysteroscopy. Fellows participate, under supervision, in surgical procedures including laparoscopy, hysteroscopy, abdominal myomectomy, robotic-assisted myomectomy and correction of genital abnormalities.
During the first year, fellows also see patients in their own clinic one-half day a week during the last 6 months with faculty supervision.
The second year of fellowship is completely research with no routine clinical duties. Fellows participate in a combination of basic science research and clinical research. Basic science activities focus on the investigation of novel progesterone receptors. Clinical research activities are varied including investigations of treatments for leiomyomata, chemoprotection of the ovary, optimization of ovulation induction techniques and optimization of gamete fertilization and culture techniques.
The third year of fellowship training is a combination of research and clinical activities. Goals include completion of research activities, presentation of research data and manuscript(s) preparation. Further clinical expertise is gained in the above mentioned areas. Two graduate level courses are taken during the 18 months of laboratory time, a course in biostatistics and one in either molecular biology or clinical research. Fellows participate in joint conferences with the divisions of Pediatric and Medical Endocrinology.
Other teaching activities include weekly case presentations with the faculty, weekly review of pre-operative patients and a RE topic, weekly departmental morbidity and mortality conference and weekly departmental grand rounds. Journal club is held monthly within the Division.
Duke REI fellows interact primarily with the REI Faculty but also with the fellows and faculty in the Division of Endocrinology, Metabolism & Nutrition (Department of Medicine) and the Division of Pediatric Endocrinology (Department of Pediatrics).
Away rotations include perinatal genetics, reproductive urology, menopausal medicine and thyroid clinic.
Two graduate school courses are taken during the Research Rotation (2nd-year):
1. The statistics course Introduction to Statistical Methods (CRP241 in the Clinical Research Training Program) is given by the Division of Biometry and Medical Informatics. A faculty member in the Department of Medicine teaches this course simultaneously for Duke and the NIH in an electronic classroom. It meets Tuesdays and Thursdays from 3:00 to 4:30 pm so it has minimum interference with the fellow’s research schedule.
2. The second required course is at the fellow’s discretion and need not be specifically within traditional "endocrinology" or "reproductive physiology" but must have some relevance to the general area of reproductive biology. Most fellows have elected to take Introduction to Medical Genetics through the Duke Clinical Research Training Program (CRTP). The course provides an in-depth analysis of cellular and molecular aspects of regulation, spermatogenesis and fertilization, oogenesis and oocyte maturation, cell cycle; cell cycle related to IVF, follicle development; gonadotropin structure/function, steroid and gonadotropin receptor regulation. Areas in which other courses have been taken include immunology, molecular genetics, neurobiology, and cell biology. Other fellows with an interest in clinical research have elected to take Principals of Clinical Research through the CRTP.
Pediatric and Medical Endocrinology Conferences
Because of the nature of the patients and the organization of Pediatric Endocrinology, the Reproductive Endocrine Division holds quarterly joint conferences with Pediatric Endocrinology to discuss clinical cases of mutual interest, i.e., pubertal problems, sexual ambiguity, etc. Historically, this has proven to be the most efficient use of the fellows' time. It has clearly widened the spectrum of endocrine disorders to which our fellows are exposed (thyroid, adrenal, growth hormones, panhypopituitarism, diabetes, etc.) without an undue commitment of time. REI fellows attend weekly Medical Endocrinology Grand Rounds depending on subject applicability.
Medical Endocrinology conferences are held each Friday and are attended by REI fellows according to the applicability of the topic.
1st (during second half of year) & 3rd year fellows have a half-day clinic session per week.
The Endocrine/Fertility Fellow is either the primary surgeon or the first assistant for all significant reconstructive surgery under the direct supervision of a faculty member.
During the Endocrine/Fertility rotation, the fellow:
- Participates in the RE&I clinics with the faculty (performing HSGs, office hysteroscopy, ultrasounds, endometrial biopsies, endocrine testing, etc.)
- Manages patients with ectopic pregnancies treated either with methotrexate or surgery
- Participates in all surgical procedures in the division (microsurgical cases, myomectomies, surgical correction of Mullerian anomalies, operative and diagnostic endoscopy)
- Counsels and manages couples where the male is considering sperm cryopreservation because of treatment for a malignancy
- Responsible for all the inpatient care of women with reproductive endocrine or infertility problems
- Responsible for the inpatient consultations from other services with appropriate oversight by the faculty
Menopausal medicine: During the 1st and 3rd years, fellows attend clinic approximately 3-6 times with Dr. Anne Ford. Dr. Ford has a large clinic where fellows may obtain more experience with routine menopausal heath issues.
Perinatal genetics: During the 1st and 3rd years, fellows attend clinic approximately 6 times with Kristin Nunez, MS. Goals are to learn genetic disorders of preconception concern and preconception techniques of PGS and PGD.
Reproductive Urology: During the 1st and 3rd years, fellows attend clinic approximately 6 times with Dr. Karen Baker. Dr. Baker is a board-certified reproductive urologist. Goals are to learn the evaluation and treatment of male infertility.
Thyroid clinic: During the 1st and 3rd years, fellows attend clinic approximately 3 times with Dr. Jennifer Perkins. Goals are to gain experience in recognition of evaluation and treatment of thyroid nodules.
IVF laboratory: 1-2 times each year the fellow will spend the day in the ART lab learning techniques, incubator gases, quality control efforts and culture conditions. On hand experience is gained by culturing and manipulating mouse embryos.
The Division is involved with multiple clinical research projects investigating all aspects of reproductive endocrinology. Clinical research nurses within the Division work closely with the physicians in recruiting research subjects, performing research protocols and analyzing research data.
Past and present investigations include:
- Novel ovulation induction techniques
- Adhesion prevention
- Prevention of chemotherapy induced ovarian failure
- Clinical parameters affecting IVF outcomes
- Relationship of chronic endometritis to IVF pregnancy rates and miscarriage
- Basic Science Research
The Molecular Endocrinology Laboratory within the Division studies the non-genomic actions of progesterone via novel receptors.
Progesterone may function to regulate cell processes including survival and apoptosis via non-nuclear receptors located in the plasma membrane and/or mitochondria. Studies include the identification and localization of novel progesterone receptors, and the regulation of cell signaling proteins and calcium mobilization by progesterone in cell line models. Possible non-genomic physiological effects of progesterone are also investigated using a mouse model lacking expression of the classic nuclear progesterone receptors.
Conferences and Seminars
- Weekly divisional conference -- discuss clinical and research subjects
- Weekly pre-op conference
- Daily IVF stimulation review (1st and 3rd-year)
- Weekly donor egg screening conference
- Weekly IVF success and failure conference
- Weekly Departmental Grand Rounds
- Weekly Departmental M&M
- Departmental clinical care conference -- given in rotation by the division
- Departmental journal club -- the division has responsibility on a rotational basis.
- Weekly Endocrine Grand Rounds when applicable
- Weekly basic science research conference (2nd year)
- Quarterly Pediatric Endocrinology Joint conference
Fellows are encouraged to publish during training. On average each fellow has 4 publications. The record by one fellow is 16, so far!!