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The Division of Reproductive Endocrinology and Infertility The American Board of Obstetrics and Gynecology, Inc.

Summer 1997



The Division of Reproductive Endocrinology and Infertility The American Board of Obstetrics and Gynecology, Inc.

INTRODUCTION This Guide to Learning in Reproductive Endocrinology & Infertility has been prepared by members of the Division of Reproductive Endocrinology and Infertility, American Board of Obstetrics and Gynecology, Inc. to provide assistance to both the Fellow in training and the Program Director. It is intended to identify the minimal acceptable level of achievement and should not be interpreted as describing the ideal or setting upper limits on learning and achievement. This guide is intended for several uses. Firstly, it should serve to guide the Program Director as to the areas of training required for an adequate fellowship program. Secondly, it can serve as a study guide for the fellow. Finally, this guide serves as a content list for the several examinations given by the Division of Reproductive Endocrinology & Infertility of the American Board of Obstetrics and Gynecology, Inc. The Division regards the Fellow as a postgraduate trainee with the implied responsibility for self study and independent inquiry. However, the Program Director is responsible for providing adequate clinical experience, technical instruction, learning resources, study guidance, and regular direct personal evaluation of the fellow. The Reproductive Endocrinologist is expected to have advanced knowledge of endocrine and fertility problems in female and male patients. He/she must have clinical competence in reproductive endocrinology and infertility and should be able to function as a consultant to obstetriciansgynecologists. Finally, this individual should be able to function effectively in the arena of basic and applied investigation in reproductive endocrinology and infertility, for only in this way does one advance the discipline and remain current in this rapidly changing field. DEFINITION OF A REPRODUCTIVE ENDOCRINOLOGIST A Reproductive Endocrinologist is a subspecialist in the discipline of Obstetrics and Gynecology who is capable of managing complex problems relating to reproductive endocrinology and infertility, and whose current professional activity involves the practice of reproductive endocrinology and infertility in a setting wherein essential diagnostic and therapeutic facilities are being appropriately utilized.


. . . . i . . . . . . . 50 . . . . . . . . . . . . .4 . . . . . . . . . . . . . . . . IX. . . . . . . . . 52 . . . . . . OVARIAN FUNCTION AND DISEASE STATES . .TABLE OF CONTENTS INTRODUCTION . . XVII. VI. . . . RESEARCH AND THESIS . . . . . . . . . . . . . . . .6 10 13 15 17 19 21 24 26 29 31 33 35 37 39 41 43 46 48 . . EMBRYOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XI. . . . . PSYCHOLOGIC AND SEXUAL IMPLICATIONS OF REPRODUCTIVE DISEASE . . . . PHYSIOLOGY AND ENDOCRINOLOGY OF THE CLIMACTERIC . . . NEUROENDOCRINE FUNCTION AND DISEASE STATES XII. . . . . . . . . . . . . . . . . . . . . . . . . . . . XIX. . . . . . . 60 . . . . . . IV. . . . . . . . . . . VII. . . . . . V. . . . . . . . . . . . II. . . . 57 . . . XXIII. . . . . . . . . . . . FEMALE INFERTILITY . PUBERTY . . . . . . . . . . . . . . . . . . . . . . . . . . XIII. . . . . . . . . . . . XXII. . . . PATHOLOGY . . . . X. ANDROGEN DISORDERS . . . . . . . . . . . . . 62 ii . . . . . XXIV. . . . . . XXVII. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IMMUNOLOGY . . . . . . . . . . . . . . . XVIII. . . ENDOCRINOLOGY OF PREGNANCY . . . . . . . . . . . . . . . . . LABORATORY CAPABILITY . . . . . . . . . . . . . . ADRENAL FUNCTION AND DISEASE STATES . . . STATISTICS . . . . . . . . . . . . . . . . . . . 55 . . . . . . . . . . . . . XXVI. . . . . . . I. . . . . THYROID FUNCTION AND DISEASE STATES . . . . . . . . . . . . . . . . . . . . . . i . . . . . . . . . . SURGICAL TECHNIQUES . III. . . . . . . . . . . . . . . . . . XVI. . . . . GENETICS . . . CLINICAL DIAGNOSTIC TECHNIQUES . . . . . . . . . . . . . . . . . . . XIV. . . . . . . . . . . . . . . . . . . . . . . . . . . . ABNORMAL UTERINE BLEEDING . . . . . . . . . . . . . . . . . . . . MALE INFERTILITY . . . . . . . . . . . . . . . XV. . . . . . . . . . . . . . . . . . . . . . . . . . . . . XXV. . AMENORRHEA . . . . DEFINITION OF A REPRODUCTIVE ENDOCRINOLOGIST . . . . . . CONTRACEPTION . . . . . . . . . . XX. . . . . RECURRENT ABORTION . . . . . . . . . . . .2 . . . XXI. . . . . . . . VIII. CLINICAL PHARMACOLOGY OF HORMONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TECHNIQUES OF ASSISTED REPRODUCTION . . . . . . . . . MECHANISMS OF HORMONE ACTION . . . . . . . . .

Mechanisms of Hormone Action 1 .I.

the mechanism of action for releasing hormones and other neural peptides. 9. the nature of steroid receptor binding to DNA and initiation of transcription. 7. molecular control of hormone and hormone receptor synthesis. internalization. 6. and second messengers. MECHANISMS OF HORMONE ACTION TERMINAL OBJECTIVES: The fellow should be familiar with the mechanisms whereby hormones exert their effects at a cellular level and be able to apply these principles to reproductive physiology and disorders of reproduction. 5. ENABLING OBJECTIVES: A. the nature of receptor assays and their usefulness. and their effect on hormone action. the mechanism of action for tropic hormones. steroid receptor defects.I. 4. To accomplish this. 2 . desensitization. the mechanism of action for steroid hormones. 2. including heterogeneity of hormones. orphan receptors. the significance of concepts involved in hormone action. receptor replenishment. 3. 8. signal transduction pathways for reproductive hormones and cofactors. the fellow should be able to understand and discuss: 1.

II. Clinical Pharmacology of Hormones


II. CLINICAL PHARMACOLOGY OF HORMONES TERMINAL OBJECTIVE: The fellow should be able to evaluate clinically and manage patients with problems related to the clinical pharmacology of hormones as related to reproductive endocrinology and infertility. ENABLING OBJECTIVES: A. The fellow should be able to: 1. define absorption, excretion, distribution, biotransformation and bioavailability of drugs and hormones, showing knowledge of these mechanisms for transfer across membranes (e.g., placenta), into and across cells, storage, metabolism, and renal, hepatic and fecal excretion. 2. discuss mechanisms of drug and hormone action including structure activity relationships, receptors and sites of action. 3. characterize drug and hormone effects, including doseresponses, biologic variations, and factors that modify effects (e.g., age, sex, body weight, route of administration, tolerance and drug or hormone interactions), teratogenicity, agonist and antagonist effects. 4. define scope and limitation of different delivery systems for steroid and glycoprotein hormones. 5. discuss the production, availability, and advantages of recombinant glycoprotein hormones.


III. Pathology


histology of trophoblast/implantation. gross and microscopic findings of adenosis. developmental stages (dating). b. myometrium the a. the fellow should be able to identify and describe for the: 1. b. vagina the a. histology of normal and abnormal endometrium. ENABLING OBJECTIVES: A. c. gross and microscopic findings of diseases related to reproductive endocrinology (e. 2. 3.g. 4. including each of the different types (i. b. endometriosis). acute and chronic salpingitis. subserosal. relationship of leiomyomata to infertility.III. e. responses to pharmacologic agents. and immunohistochemical techniques as they relate to the diagnosis and further clarification of reproductive endocrine pathology. intramural and submucosal). miscroscopic histology. 6 .e. current data relating to estrogen and progestins and endometrial hyperplasia and adenocarcinoma.. pathophysiology and possible consequences of antenatal hormone exposure. 5. d. b. b. PATHOLOGY TERMINAL OBJECTIVE: The fellow should have a knowledge of gross. natural history and clinical course of acute and chronic salpingitis as they relate to subsequent fertility. For the specific organs listed below. oviduct the a. mechanisms of action and effects of hormones. cervix the a. leiomyomata and other myometrial findings related to reproductive endocrinology. pathophysiology and possible sequences of antenatal hormone exposure. gross and microscopic findings of adenomyosis.. c. endometrium the a. mechanisms of action and effects of hormones upon the vagina and be able to interpret cytograms. salpingitis isthmica nodosa. granulomatous salpingitis.

granulosa cells. 9. testis the a. corpus luteum.e. adenoma. gross and microscopic findings and the natural history of functional and neoplastic ovarian tumors as they relate to reproductive endocrinology (i. changes which occur in the ovary from embryonic life to menopause. lesions associated with altered reproductive functions (i. anatomy and function of the neurohypophysis. luteoma. cerebral cortex. thyroid lesions associated with altered reproductive function (e. carcinoma. specific staining techniques and cellular ultrastructure as they relate to function.g. hyperplasia. theca and adjacent stroma) and the primordial. 11. b. oocyte. including the dynamic. gross and microscopic findings in the normal testis. cellular morphology of normal and neoplastic cells of the adenohypophysis. b. 8. 7 . other endocrinologically related central nervous system structures (e. primary hypothyroidism. adrenal the a. individual compartments of the Graafian follicle (i. normal structure.e. accessory sex organs and testicular disease.. dysgerminoma. granulosa-theca cell tumor. normal structure. thyroiditis. preantral and antral follicles.6.. anatomy and functional relationships of the various hypothalamic centers involved in reproductive endocrine functions.. b. hypothalamus-CNS axis the a. endometrioma. b. Graves' disease. 7. cystic teratoma. thyroid the a. b. follicular cysts. stages of normal and abnormal spermatogenesis. Sertoli-Leydig cell tumor. d.. histology of the polycystic ovary. ovary the a. gynandroblastoma. 10.. e. pituitary the a. c. third ventricle. pheochromocytoma). neoplasia).g. pineal gland). b. gonadoblastoma and mixed germ cell tumors).e. gross and microscopic appearance of gonadal structures in various forms of gonadal dysgenesis and intersexuality.

placenta the a. peritoneum the a. b. For the specific organs listed above under A. the fellow should be able to use immunohistochemistry and DNA-RNA hybridization techniques to localize the site and temporal specificity of endocrine. specific cells responsible for protein and steroid hormone production. microscopic anatomy. lesions associated with endometriosis.12. c. healing and scarring processes (pelvic adhesions). 8 . structural characteristics necessary for maintenance of fetal well-being. 13. b. paracrine and autocrine regulation of these tissues relating to reproductive function. B.

Immunology 9 .IV.

b. condom. ENABLING OBJECTIVES: To accomplish this. basic components of the immune system and their possible role in male and female reproductive failure.. as well as their implications for infertility in both male and female. proposed etiologies of isoimmunization against seminal antigens in the male. origin and function of “T". IMMUNOLOGY TERMINAL OBJECTIVE: The fellow should be able to evaluate. characterization of assay systems.g. mechanism of antibody production. c. post-coital test. f. production. d. g. clinical aspects related to infertility including the a. possible role of cellular and circulating antibodies in infertility with specific reference to a. 3. "B". washed spermatozoa. c. techniques and interpretation of diagnostic procedures (i. origin and function of IgA. and applications of polyclonal and monoclonal antibodies with respect to reproductive disorders. 10 .e. role of cytokines in the immune system with regard to reproductive function and disorders. diagnose and manage patients with infertility and endocrinologic diseases of immunologic origin. IgM. b. recurrent abortion. h. their diagnosis and therapy. premature ovarian failure.. mediation of cytokine immunologic signals. various modes of treatment for "immunologic infertility" and their limitations (e. infertility and contraception. tests for antisperm antibodies). various sexually transmitted diseases.IV. IgG and IgE. possible significance of sperm agglutinating and sperm immobilizating antibodies and head-to-head and tail-to-tail agglutination. the fellow should be able to understand and describe the: 1. e. "helper" and "suppressor" lymphocytes.) c. definition of and examples of autoimmune disease. essentials of basic immunology including the a. 2. donor cervical mucus) and expected results. b.

7.4. gonad). effect of active and passive immunization on hormone producing target tissues. 6. principles of immunologic contraception. pathophysiology of autoimmune disease to gonadal failure and other endocrine dysfunction. 5. adrenal..e. 11 . thyroid. clinical features of autoimmune endocrinologic disease (i.


including a description of factors thought to be involved in the control of oocyte maturation. vaginal agenesis. surgical approach. and adrenal gland. feminizing genitoplasty. transverse vaginal septum. anatomy. including factors controlling the development of the gonadal primordia. thyroid gland. transverse vaginal septums. embryonic development and anatomy of the genital tract. clitoral reduction. and müllerian anomalies. 4. processes of oocyte and sperm maturation and the mechanism of fertilization. mechanisms for the various developmental aberrations of the reproductive tracts including müllerian and gonadal abnormalities. exteriorization of vagina. embryology and anatomy of' the hypothalamic-pituitary system. EMBRYOLOGY TERMINAL OBJECTIVES: The fellow should be able to diagnose and manage patients with congenital abnormalities of the female internal and external genitalia as well as sexual ambiguity.V. 2. 3. ENABLING OBJECTIVES: To accomplish this. the fellow should be able to understand and describe the: 1 . and imperforate hymen. 5. and management for vaginal agenesis. accessory reproductive structures and external genitalia in the male and female. 13 .


). DNA-RNA detection (e.g. 2.. Klinefelter syndrome. techniques of gene amplification (e. single gene disorders. 5. including gametogenic errors. PCR) and other assay systems (FISH.. chromosomal structure and standard cytogenetic nomenclature.g. GENETICS TERMINAL OBJECTIVES: The fellow should be able to interpret pedigree data and care for patients with inherited and sporadic genetic disorders affecting the male and female reproductive system. cytogenetic abnormalities. gonadal dysgenesis. congenital adrenal hyperplasia. normal genetics. Kallmann syndrome. infertility and recurrent abortions and describe the roles of meiotic errors. 15 . etc. 4. and prior to assisted reproduction using donor sperm or donor oocyte. 3.g. and molecular mutants referable to reproductive endocrine disorders (e.). abnormal genetics. ENABLING OBJECTIVES: The fellow should be able to apply (use) genetic concepts and techniques to diagnostic problems in reproductive endocrinology and be familiar with: 1. techniques of chromosomal karyotyping. and DNA diagnosis referable to reproductive endocrinology. routine preconceptional screening for genetic disorders in couples with reproductive problems. Southern blotting. Northern blotting). gene structure and regulation.VI. growth hormone deficiency Type IA.. cytogenetic abnormalities and embryonic lethal mutations. etc.

VII. Endocrinology of Pregnancy 16 .

feto-placental unit as it relates to the biochemistry. 7. including the possible role of renin.VII. protein and polypeptide hormones. initiation of parturition. ENDOCRINOLOGY OF PREGNANCY TERMINAL OBJECTIVES: The fellow should be able to discuss maternal and fetal physiology and pathophysiology and diagnose and manage endocrinopathy in obstetrical patients. cytokines. intra and postpartum diagnosis and management of thyroid. the fellow should be able to understand and discuss the: 1. selection and interpretation of endocrine assays during the course of pregnancy. placental transfer of hormones and their effects on fetal development. including the role of prostaglandins. adrenal and pancreatic function during pregnancy. 9. production of endometrial/decidual hormones . 6. physiology of the fetal adrenal gland. 3. 10. 11. aldosterone and prostaglandins. parathyroid. 8. placental steroid hormones and adrenal steroids. 5. physiology and pathophysiology of steriod. endocrine pathophysiology of preeclampsia-eclampsia. 2. angiotensin. physiology and pathophysiology of fetal hypothalamic-pituitarygonadal function and pancreatic function. altered maternal thyroid. 4. ENABLING OBJECTIVES: To care for such patients. 17 . intra and postpartum diagnosis and management of hypothalamic-pituitary abnormalities. pancreatic and adrenal disease.

VIII Laboratory Capability 18 .

Western blotting and Northern/Southern blotting techniques. including immunoassay. and identification of steroid and protein hormones. 2. enzyme kinetics. validation of immunohistochemical. precision. LABORATORY CAPABILITY TERMINAL OBJECTIVES: The fellow should be able to discuss the nature. interpret and. 19 . as well as their statistical analysis. application. interconversion and metabolism of specific hormones. biochemical methodology. 5. kinetics of production. and assay drift. where appropriate. ENABLING OBJECTIVES: The fellow should be able to explain the scope and limitations. bias. purification. experimental design. specificity. as they relate to steroid and protein metabolism. assay validation and description of standard curve. and methodology of hormone assays in reproductive endocrinology. including: 1. specific techniques for hormone assays of various types. bioassay and receptor assay.VIII. including extraction. distribution. 6. sensitivity. 7. carry out laboratory elements of clinical and basic reproductive endocrinology. 4. data interpretation. and statistical analysis. 3.

IX. Statistics 20 .

c. c. and e. ENABLING OBJECTIVES: The fellow should be able to: 1. compute and interpret measures of comparisons of means and variations. 5. use one-way and two-way analysis of variance. and retrospective case control studies. 2. significance of the results. Relate these techniques to the analysis of fecundibility and conception rates in infertile couples. b. the question examined. 4. f. and "Type II error".g. apply the following statistical tests: a.. regression analysis. and g. describe the methods of performing and limitations of prospective. the conclusions. correlation analysis. T-test. d. "Type I error". chi-square. define and calculate assay variation. e. 21 . person year exposure). "confidence interval". the hypothesis. 8. use the least squares regression line and calculate unknowns from standards in radioimmunoassay. paired and independent. 6. 3. the expression and correlation of raw data. Pearl's index. 11. differentiate population parameters and sample statistics. define the indications and use of Non-Parametric versus Parametric Tests. d. use logarithmic and logit transformations. 9. 10. "significance". define the terms “coefficient of variation”. the appropriate inferences which can be obtained from the data.IX. 7. life table analysis and other related statistical methods (e. STATISTICS TERMINAL OBJECTIVES: The fellow should be able to design and analyze experiments utilizing conventional biostatistical tools. analyze a presented experiment and construct a hypothetical experiment with respect to a. cohort. the sampling technique (including sampling bias). b.

12. describe the clinical assessment of a test to include sensitivity. 22 . positive and negative predictive values and relationship to prevalence. 13. specificity. understand the principles and pitfalls of meta-analysis.

X. Clinical Diagnostic Techniques 23 .

CLINICAL DIAGNOSTIC TECHNIQUES TERMINAL OBJECTIVES: In patients with endocrinologic disease or infertility the fellow should be able to take a comprehensive medical history. bone densitometry and establishment of bone age.X. including biopsies of the endometrium. including blood chemistries performed on biologic fluids. obtain) and interpret results of these diagnostic techniques: 1. operative. arterial and venous catheterization. 2. parathyroid. accomplish and interpret the diagnostic techniques needed to establish a diagnosis. select. including hysterosalpingography. evaluate co-existing disease or factors which may have a bearing on selection of and response to treatment. Describe clinical conditions (e. sonohysterography and genitography. radioisotope scanning techniques. adrenal and gonadal systems. pregnancy. ultrasonography.. radiographic and imaging. and laparotomy. 3.g. 4. and evaluate the response to therapy. perform a general physical examination in addition to a specific gynecologic history and physical examination. sella turcica radiography. biochemical. organize. thyroid disease) in which endocrine test results may be altered. magnetic resonance imaging. computerized tomography. laparoscopy and hysteroscopy. including endocrinologic and genetic evaluation of the fetus. the fellow should be able to describe. ENABLING OBJECTIVES: To accomplish this. perform (or where appropriate. Be able to perform and interpret dynamic endocrinologic testing of these systems. thyroid. including the measurement of hormones in biological fluids for evaluation of the hypothalamus. endocrinologic. obstetrical. pituitary. 5. 24 .

XI. Neuroendocrine Function and Disease States 25 .

and their target organ feedback systems. including long and short-term biorhythmicity. somatostatin. sexually dimorphic nuclei. and target cells of the pituitary. biochemical basis of the neuroendocrine interactions and the use of neuropharmacological agents. 3 . 16. distribution and cellular characteristics of pituitary hormone producing cells with special reference to gonadotrope. 8.) 10. anatomical-functional relationships of the hypothalamus. proopiomelanocortin family. 6. supra-hypothalamic structures and neuronal systems relevant to regulation of reproductive processes. NEUROENDOCRINE FUNCTION AND DISEASE STATES TERMINAL OBJECTIVES: The fellow should be able to discuss neuroendocrine physiology and function and to diagnose and manage patients with diseases originating in the neuroendocrinologic system. ENABLING OBJECTIVES: To accomplish this. 14. 5. structure and function of pituitary reproductive hormones and neuropeptides (GnRH. neuroendocrine function of the fetal-placental unit. circumventricular organs and blood brain barrier. GHRH. 15. 7. regulatory secretory activities of the pituitary hormones. vasopressin and neurophysins (the posterior hypophesis). hypersecretory syndromes. organic lesion and/or functional disorders of the hypothalamicpituitary system. ectopic hormone producing syndromes. the site of production. biochemical basis of neuropharmacology of agonists and antagonists. biological action and control of secretion of oxytocin. 9. 12. the fellow should be able to understand and discuss: 1. etc. 26 . CRH.XI. somatotrope and lactotrope. TRH. anatomical arrangement of hypothalamic-hypophyseal portal circulation. 11. 13. 2. neuroendocrine regulation of the menstrual cycle. vasopressin. 4. neurovascular.

panhypopituitarism. 27 . deficiencies of the hypothalamic-pituitary system (i..e.17. Sheehan syndrome. Kallmann syndrome and isolated pituitary hormone deficiencies).

Ovarian Function and Disease States 28 .XII.

age-related changes in ovarian structure. 3. atresia. 12. corpus luteum development. 8. ovarian activity during gestation. hetero-autoregulation of hormone receptors and down-regulation. 11.XII. hormone producing tumors of the ovary. 29 . progestins and other therapies. synthesis and secretion of steroid hormones by the various compartments and cell types of the ovary. 9. 13. 6. function and regulation. the fellow should be able to understand and discuss: 1 . cyclic changes in endocrine activities within the ovary. events leading to the development of a normal primary oocyte. maintenance and regression and steroidogenesis and to diagnose and manage patients with diseases involved in these systems. autocrine and paracrine effects of cytokines and growth factors on ovarian function and on the oocyte. germinal vesicle breakdown and completion of meiosis I. 5. recruitment and selection of the dominant follicle and oocyte maturation. 16. OVARIAN FUNCTION AND DISEASE STATES TERMINAL OBJECTIVES: The fellow should be able to discuss ovarian physiologic processes including folliculogenesis. 4. 15. mechanisms of protein/steroid hormone action in the ovary (including apoptosis). hypothalamus/pituitary control of ovarian function. 10. clinical and pathophysiologic correlates of disorders of the human ovary (structure and function). 2. various therapies for primary or secondary hypogonadotropic patients and the rationale for the use or non-use of estrogens. including its physiology and pathophysiology. the pathophysiology of polycystic ovary syndrome. 7. 14. ovulation. as well as the management of patients during the perimenopause and menopause. luteolysis. ENABLING OBJECTIVES: To accomplish this. the testing procedures needed in primary or secondary hypogonadism.

XIII. Thyroid Function and Disease States 30 .

9. pregnancy and hormone induced changes of thyroid function in the mother and the effect of abnormal maternal thyroid function on the fetus. TBG.and hyperthyroidism. infertility and pregnancy. 12. 5. the scope. 2. pituitary. 31 . 6. deficiencies of the thyroid. 8. T3 uptake. fetal and newborn thyroid physiology. the pharmacology of thyroid medications. thyroid function in struma ovarii. 3. the therapy of hyperthyroidism and hypothyroidism. or hypothalamic disease. including hypothyroidism in pregnant or non-pregnant women and women on various hormonal medications. THYROID FUNCTION AND DISEASE STATES TERMINAL OBJECTIVES: The fellow should be able to discuss thyroid function and physiology and be able to diagnose and treat patients with thyroid disorders. 7. the biosynthesis. ENABLING OBJECTIVES: In order to accomplish this. and limitations of laboratory testing for thyroid function (TSH. including the differentiation of hypothyroidism resulting from thyroid. diagnostic value.XIII. the fellow should be able to understand and discuss: 1. the clinical and pathophysiological correlates of hypo. TRH-TSH-thyroid physiology. T4. 10. particularly as related to menstrual disorders. 4. free T4 and reverse T3). the pathophysiology of autoimmune disorders involving the thyroid. control and metabolism of thyroid hormones. the effects of thyroid replacement and anti-thyroid drug therapy on the fetus. molar pregnancy and choriocarcinoma. 11. T3 RIA.

XIV. Adrenal Function and Disease States 32 .

17-20 desmolase. In order to accomplish this. 10. 7. 6. 2.XIV. ADRENAL FUNCTION AND DISEASE STATES TERMINAL OBJECTIVES: The fellow should be able to discuss adrenal function and physiology and be able to diagnose and treat patients with adrenal disorders. clinical and laboratory assessment of adrenocortical function. development and function (17 alpha hydroxylase deficiency. B. carcinoma). aldosterone and disorders of the renin-angiotensin system.and hyperactivity (e. ENABLING OBJECTIVES: A. The fellow should be able to diagnose and treat any of the above abnormalities. 17 ketoreductase.). adrenal crisis. 2.g. including Nelson syndrome. etc. adrenocortical hypo.. steroid pathway enzyme defects and their effect on gonadal. the fellow should be able to understand and discuss: 1. 8. genetics and biochemistry of specific steroid pathway defects in the congenital adrenal hyperplasias. 9. syndromes of excess catecholamine secretion. effects of aberrations of adrenocortical function on hypothalamic-pituitary-ovarian function. adenoma. deficiencies of the adrenal. pharmacology of naturally occurring and synthetic glucocorticoids and mineralocorticoids. including 1. the requirements for long-term hormone replacement. 4. Cushing syndrome. including hypoadrenalism resulting from pituitary or adrenal disease or hormonal medications in pregnant or non-pregnant women. 33 . 5. 3. regulation and secretion of adrenocortical hormones.

Androgen Disorders 34 .XV.

ENABLING OBJECTIVES: To treat such patients. describe the symptoms and signs of androgen excess. 9. 15. differentiate between adrenal and ovarian etiologies of normal androgen production. physiology. including 5 alpha reductase deficiency. benign and malignant. 4. describe radiologic and imaging procedures commonly used for diagnosis in women with hyperandrogenism. describe the indications for and the use of CT and MRI imaging. 35 . particularly as it relates to spermatogenesis and sexual behavior. as well as the use for selective catheterization of the ovarian and/or adrenal veins. 3. 12. including neoplasms. discuss ovarian tumors. describe the treatment of androgen excess.XV. 11. discuss the physiology of normal and abnormal hair growth. the fellow should be able to: 1. differentiate hirsutism from defeminization. 14. general metabolic effects and treatment. 13. relate polycystic ovary syndrome to abnormal androgen secretion and hirsutism. 10. which may be androgen secreting. 7. genetic factors. describe the mechanism of androgen action. 8. define secretion. describe those benign stromal changes in the ovary which may result in virilism. and metabolism of androgens in normal women. virilization and hypertrichosis. 5. ANDROGEN DISORDERS TERMINAL OBJECTIVES: The fellow should be able to discuss and be able to diagnose and treat patients with androgen disorders. describe mechanisms of androgen production and their control in the male. 6. indicate the role of hormone assays in evaluating hyperandrogenism. genital morphology. 2. differentiate between non-classical variants and classical adrenal hyperplasia in terms of etiology.

XVI. Abnormal Uterine Bleeding 36 .

relate abnormal bleeding to such intercurrent diseases as obesity. the fellow should be able to: 1. discuss anovulation and the resultant hormonal changes. secretory changes. 10. including the pharmacology and rationale for drugs used in its treatment. 5.XVI. including the role of prostaglandins in the menstrual cycle and the physiology of the cessation of menstrual bleeding. 7. and androgen. and thyroid disorders. indicating effects on the endometrium. 8. and methods of estimating blood loss. and menstruation. including spiral arteriolar change. describe the medical treatment for abnormal bleeding. 3. describe the normal menstrual cycle. describe the role of hysteroscopy and sonohysterography. 37 . lysosome stability and fibrinolysis. 9. 2. blood dyscrasias. describe the coagulation abnormalities which may produce uterine bleeding. changes in circulating gonadotropins and steroid hormones. Relate hormone levels to the endometrial effects of estrogen. 4. 6. ABNORMAL UTERINE BLEEDING TERMINAL OBJECTIVES: The fellow should be able to discuss the problems of and to diagnose and manage patients with abnormal uterine bleeding. discuss the indications for surgical management and the possible surgical techniques. define the terms used to describe abnormal uterine bleeding. progesterone. discuss the molecular effects of steroids in relation to proliferation of the endometrium. discuss limits of normal menstrual blood loss. ENABLING OBJECTIVES: To treat such patients.

Amenorrhea 38 .XVII.

the interpretation of tests utilized in the evaluation of amenorrhea. the secretion of steroid hormones and gonadotropins. acromegaly. Kallmann syndrome. the techniques for and ability to carry out the evaluation and therapy of patients who require ovulation induction. a rational diagnostic and therapeutic cost-effective approach to patients with amenorrhea. ENABLING OBJECTIVES: To diagnose and treat such patients.g.). the physiology and pathophysiology of prolactin secretion and the diagnosis and management of patients with hyperprolactinemia. the clinical manifestations of diseases associated with amenorrhea (e. including pharmacological effects. hypopituitarism. 8. 5. 2. growth and developmental aspects of amenorrhea as they relate to puberty and the menarche. the pathophysiology of amenorrhea as it relates to end-organ structure and function..XVII. Sheehan syndrome. 7. 4. abnormalities of the hypothalamic control of pituitary function which result in amenorrhea. polycystic ovary syndrome. 39 . and the function of related endocrine systems. 6. 3. etc. the fellow should be able to understand and discuss: 1. AMENORRHEA TERMINAL OBJECTIVES: The fellow should be able to diagnose and treat patients with amenorrhea.

Puberty 40 .XVIII.

normal sequence and timing of pubertal changes in the female and male. 3. 5. sexual precocity syndromes including the pathophysiology. develop a plan for differential diagnosis and treat patients with abnormal pubertal development. differential diagnosis. evaluation and appropriate therapy for delayed puberty. ENABLING OBJECTIVES: The fellow should be able to understand and discuss the: 1. evaluation and appropriate therapy. 2. differential diagnosis. 41 . the role of adrenal androgens. 4. gonadotropin secretion in the fetus and neonate. sensitivity of the feedback system during fetal and neonatal life and childhood. hormonal changes relative to the reproductive cycle from intrauterine life to the development of normal reproductive cycles (e.XVIII. and epiphyseal closure. PUBERTY TERMINAL OBJECTIVES: The fellow should be able to discuss the physiology of growth and development as it relates to normal puberty. effects of gonadal and adrenal hormones on sexual development. recognize deviations from normal. pathophysiology..g. and the effects of weight changes). somatic growth. including Tanner stages.

XIX. Female Infertility 42 .

indications for tubal reparative procedures including the specific indications for microsurgery and laser surgery. bromocryptine and other agents. 2. appropriate monitoring of ovulation induction including estrogen determinations. including: correct utilization and interpretation of basal body temperatures. and LH assays. androgen therapy. tubal disorders. 43 . c. hysterosalpingography and laparoscopy).e. such as hysterogram and hysteroscopy and indications and techniques for corrective procedures. the rationale for pharmacologic adjuncts to surgical therapy. FEMALE INFERTILITY TERMINAL OBJECTIVES: The fellow should be able to evaluate a woman for infertility and be able to develop and carry out an appropriate plan for management of the infertile woman. including polycystic ovary syndrome. b. including: correct utilization and interpretation of studies of the uterine cavity. d. selection of ovulation induction utilizing clomiphene. indications for surgery for these diseases. including correct utilization and interpretation of studies of tubal function (e. human gonadotropin.. CNS-hypothalamic-pituitary syndromes and other GnRH causes. pseudopregnancy. plasma progesterone and endometrial biopsy. 3..XIX. take an appropriate history and do a physical examination oriented to infertility. knowledge related to a. danazol. describe and apply in the overall management of the infertile couple. uterine factors.g. knowledge of the medical management of endometriosis (preservation of fertility) (i. ultrasound. ovulatory disorders. ENABLING OBJECTIVES: The fellow should be able to: 1. endometriosis and other peritoneal causes of infertility. continuous progestin. diagnoses of causes of anovulation. syndromes of inappropriate prolactin secretion. and GnRH and its analogs). evaluate an infertile female.

antibiotic. g. (3) screening of sperm donors to exclude transmissible infection (HIV. cite the incidence of infertility as related to age and the prognosis for treatment of infertility. including the (1) statistics related to the effectiveness of therapies used to treat various forms of infertility. estrogen. (4) proper use of sperm cryo-banking. outcome of various managements. artificial insemination (cervical and intrauterine).e. inadequate mucus production and cervical antibody formation).g. and (2) use of life tables and meta-analyses. cervical factors. chronic cervicitis. i. 44 . familiarity with various local agencies and legal implications dealing with adoption. including the several causes of cervical infertility (e. insemination homologous and heterologous). including the indications for adoption.g. 4. including knowledge and evaluation of current methods of diagnosis and therapy. including the: (1) indications and contraindications. knowledge of appropriate counseling methods. f. application of current therapeutics (e.) and genetic disorders and. unexplained infertility. etc. utilization and interpretation of the various tests of cervical mucus-sperm interaction. h. cryosurgery. adoption. (2) evaluation of male infertility.

XX. Male Infertility 45 .

b. the biosynthesis of steroids and regulatory control of the human testis and the biological action of testosterone in man. d. j. 46 . the physiology and pathophysiology of ejaculation. the formation and content of seminal fluid. including diseases which inhibit it. e. including endocrinologic control. h. including microscopic procedures to facilitate fertilization (ICSI. take an appropriate history and do a physical examination oriented to infertility. methods of evaluating semen quality and fertilizing capabilities. c. environmental factors. mechanisms and its abnormalities. abnormalities in sperm transport including ductal obstruction and retrograde ejaculation. including drugs that may affect the endocrine and exocrine function of the testis. f. evaluate an infertile male. MALE INFERTILITY TERMINAL OBJECTIVES: The fellow should be able to evaluate the male partner and diagnose relative and absolute infertility and evaluate and discuss patients with these problems. 3. understand and discuss: a. vas and testicular sperm aspiration) and their limitations. g.XX. normal male sexuality throughout the life cycle. male hypogonadism. the medical and surgical therapies of male infertility. the cycle of spermatogenesis. ENABLING OBJECTIVES: The fellow should be able to: 1. 2. i.

Recurrent Abortion 47 .XXI.

including hypothalamic. including radiation and teratogenic exposure. to recurrent pregnancy losses.XXI. 6. congenital or acquired. contribution of environmental exposure. prognosis for patients who have lost one. genetic causes and mechanisms of cytogenetic abnormalities in embryonic lethality. pituitary. to recurrent pregnancy losses. lupus anticoagulant and anti-cardiolipin antibodies to recurrent pregnancy losses (antiphospholipid antibody syndromes). 5. 7. contribution of systemic disorders. 8. contribution of mullerian and other anatomical anomalies. including their relative incidence. causes of euploidic and aneuploidic abortion (sporadic or recurrent). four or more pregnancies. including HLA types. three. contribution of endocrine factors. Outline the arguments for and against each of these factors as a cause of infertility or recurrent pregnancy loss. including diabetes and autoimmune disorders. realistic prognosis for patients undergoing and not undergoing different treatments. 48 . contribution of immunologic factors. 3. adrenal disorders and corpus luteum defects to recurrent pregnancy losses. 9. 2. 4. diagnostic and therapeutic plan for a given patient presenting with recurrent pregnancy losses. 10. to recurrent pregnancy losses. RECURRENT ABORTION TERMINAL OBJECTIVE: The fellow should be able to diagnose and manage patients with recurrent pregnancy wastage. two. ENABLING OBJECTIVES: The fellow should be able to understand and discuss the: 1. thyroid.

Psychologic and Sexual Implications of Reproductive Disease 49 .XXII.

XXII. including stress. 6. psychological changes associated with the puerperium. 7. 4. 2. psychodynamics of premenstrual tension and menopause and the therapy of these problems. general concepts of normal and abnormal sexual function. 10. pathophysiology of erectile dysfunction and its psychological. PSYCHOLOGIC AND SEXUAL IMPLICATIONS OF REPRODUCTIVE DISEASE TERMINAL OBJECTIVE: The fellow should be able to discuss the psychologic and sexual implications of disease or dysfunction of the endocrine reproductive system. effects of infertility diagnosis and infertility. 11. antenatal hormone influence on subsequent behavior and psychologic function. psychologic changes associated with infertility. puberty and the establishment of the gender role. psychodynamics of growth and development. medical and surgical treatment. 50 . ENABLING OBJECTIVES: The fellow should be able to understand and discuss the: 1. in amenorrhea. role of psychodynamics. 8. and in particularly how this relates to reproductive endocrinology. 9. and recurrent pregnancy loss. sexuality of women throughout the life cycle. 5. 3. psychologic and sexual changes associated with hormonal therapy.

XXIII. Surgical Techniques 51 .

ovarian cystectomies. 4. diagnostic and therapeutic techniques. b. staging and treating endometriosis. including all techniques used for a. neovaginal construction (dilation and surgical methods). correction of müllerian abnormalities. vaginoplasty. reconstruction of uterine anomalies. correction of imperforate hymen. including hysterosalpingography and endoscopy (laparoscopy and hysteroscopy). To accomplish this. b. g. developmental disorders. the fellow should be able to understand. exteriorization of the vagina and feminizing genitoplasty). ENABLING OBJECTIVES: A. clitoral reduction. removal of vaginal septae. including pre and post operative medical adjunctive therapy. tuboplasty. infertility surgery. myomectomies. h. d. c. ambiguous genitalia. including a. d. resection of pelvic adhesions. discuss and perform the following surgical procedures associated with: 1 . 52 . assignment of sex of rearing for an infant with ambiguous genitalia.g. including laparoscopy and laparotomy techniques used to reverse sterilization. restoration of cervical competence. identify results and perform surgical procedures appropriate to reproductive endocrinology. f. fertility control. 3. 5. c. 2. b. resection of uterine synechiae. indications for surgical construction of unambiguous functioning female external genitalia and vagina (e. including all techniques used for a. SURGICAL TECHNIQUES TERMINAL OBJECTIVES: The fellow should be able to discuss the indications for.XXIII. e.

cite the principles of the physical modalities used in reproductive surgery. recognize surgical complications.indications and techniques for prophylactic gonadectomy. 53 . 2. The fellow should be able to: 1. including the incidence and prevention of immediate and late complications of reproductive and infertility surgery. B. c.

Techniques of Assisted Reproduction 54 .XXIV.

mechanisms controlling oocyte development and maturation. 9. techniques for preservation of embryos. implications of different specific diagnoses and their expected success rates with treatment. 10 techniques for embryonic diagnosis. transvesical. 13. and transvaginal oocyte recovery. infection) and their prevention and treatment. 6. 15. complications of ART (multifetal pregnancy. ENABLING OBJECTIVES: To accomplish this objective. facilities and personnel required for such a program. the fellow should be able to describe and/or discuss the: 1. 4. 7. selection of patients for IVF. technique of embryo transfer. methods for oocyte retrieval. gamete intra-fallopian tube transfer (GIFT) and related techniques and know the expected results. problem of multifetal pregnancy. TECHNIQUES OF ASSISTED REPRODUCTION TERMINAL OBJECTIVE: The fellow should understand the principles of extracorporeal fertilization and embryo transfer. 11. appearance of the mature compared with an immature oocyte and relate this to the method of stimulation. 3. 2. impact of maternal age on all stages of ART. use of donor oocytes and embryos and how micromanipulation of gametes and fertilized eggs may be useful.XXIV. 14. techniques for extracorporeal fertilization and in-vitro growth of embryos. 55 . 12. intra abdominal and retroperitoneal hemorrhage. methodology for induction of preovulatory follicles and describe methods for monitoring follicular development. 5. 8. severe ovarian hyperstimulation syndrome. including ultrasound directed transabdominal.

XXV. Physiology and Endocrinology of the Climacteric 56 .

fluoride. contraindications and alternatives to hormone therapy. serum lipid fluctuations. accelerated bone loss. 9. 7. significance of changes in the production and intermediary metabolism of estrogen with advancing age. calcitonin. 5. advantages and disadvantages of hormone substitution therapy in physiologic menopause or other hypogonadal states. ENABLING OBJECTIVES: To accomplish this end the fellow should be able to understand and discuss the: 1. 3. including biphosphonates. as well as use of vitamin D and calcitonin therapy. approaches used in the management of osteoporosis. different forms of hormone therapy (estrogen only. basic clinical assessment and subsequent monitoring techniques to evaluate the effects and progression of somatic and ovarian aging. earliest changes in the endocrine function of the ovary that occur in the peri-menopausal period. 2. modes or protocols for administration. 8. 6. general approaches used to ameliorate the effects of aging and estrogen deficiency with respect to risks of breast and endometrial cancer. PHYSIOLOGY AND ENDOCRINOLOGY OF THE CLIMACTERIC TERMINAL OBJECTIVE: The fellow should be familiar with the physiologic changes and aberrations that occur in psychological. techniques used to assess bone turnover and bone composition. 4. and early malignancy. significance of changes in lipid and bone metabolism that accompany physiologic aging in the female. 10. techniques used for the surveillance of cardiovascular changes.XXV. scope and limitations of biochemical assessments of serum lipids. etc. estrogen plus progestin. androgens and newer synthetic estrogens). side effects. 11. somatic and endocrine function with age. 57 .

12. 14. non-hormonal and lifestyle recommendations for women in their 50's. 58 . 13. hormonal. 60's and beyond. direct effects of steroids on vascular endothelium. the detection of early signs of maladjustment. and the symptoms suggestive of underlying psychiatric disease. normal psychologic changes with increasing age.

XXVI. Contraception 59 .

describe the various steroids used in contraceptive formulations. 2. disadvantages. thromboembolic episodes. liver disease. 4. and metabolic side effects. metabolic clearance. and failure rates of the various contraceptive methods. migraine. and be able to select the most appropriate method for a high risk patient. pelvic infections. coronary disease. 3. 60 . sickle cell anemia.XXVI. intermediary metabolism. etc. discuss potential methods of male contraception. ENABLING OBJECTIVES: To accomplish the terminal objective the fellow should be able to: 1. discuss the specific type of contraceptive for high risk subjects with histories of breast or endometrial cancer. hypertension. CONTRACEPTION TERMINAL OBJECTIVE: The fellow should be familiar with methods of contraception. effective route of administration. and be able to relate their chemical structure to potency. describe the advantages.

Research and Thesis 61 .XXVII.

do the numbers add up properly and can the different tables be reconciled. What is the population to be studied? c. What is the sensitivity.) 5. case control study. How comparable is the control group? d. What is the population to which the investigators intend to apply their findings? 2. Are there clear definitions of the terms used? (i. specificity and predictive values of the methods? 4. and in sufficient detail? b.e. Observations a. are the methods of analysis appropriate to the source and nature of the data? b. Are the observations reliable and reproducible? c. or a retrospective analysis of records? b. planned observations. What are the study objectives? b. Are the findings internally consistent? (i.XXVII. Design of the Investigation a. etc. randomized clinical trial. Presentation of Findings a. What is the statistical (study) power? 3.e. diagnostic criteria.. Hypothesis a. inclusion criteria.. objectively. Are there possible sources of sample selection bias? c. RESEARCH AND THESIS TERMINAL OBJECTIVE: The fellow should be able to participate fully in the theoretical and technical aspects of clinical and/or basic science research projects. Was the study an experiment. measurements made and outcome variables) b. Are the findings presented clearly. Analysis of the Results a. 1. Are the data worthy of statistical analysis? If so. Is the analysis correctly performed and interpreted? 62 . ENABLING OBJECTIVES: The fellow should write a thesis which is a scholarly publication and be able to defend it according to the following outline.

63 . Are the conclusions relevant to the hypothesis? 7.. Conclusions or Summary a. age.e. sex. Is design of the study appropriate for solving the stated problems? e. or in other relevant variables) d. in fact. Is there mention of the type of test used or the significance level? g. Breadth and Depth of Subject Matter Is the candidate knowledgeable about the reference or cited material? c. 8. Which conclusions are "justified” by the findings? b. clinical characteristics. be due to a lack of comparability of the groups? (i. Is there an improper use of statistical techniques? f.Is there sufficient analysis to determine whether "significant differences" may. Is there use of measured sensitivity without specificity? 6. the candidate should suggest a revised experimental design that would provide reliable and valid information relevant to the questions under study. Redesign the Study If the study could be improved.