Reproductive Medicine Division

Department of Obstetrics and Gynecology

Faculty of Medicine

Prince of Songkhla University

Curriculum

for

Subspecialty Training

in

Reproductive Medicine

1

Table of Contents

Page

I Introduction 2

II Purposes 3

III Educational objectives 3

IV Contents 5

V Learning experience (Training program) 24

VI Evaluation 26

VII Requirements for trainees 26

VIII Staffs 26

IX Clinical workload and facilities 28

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I. Introduction

Subspecialists in reproductive medicine are gynecologists having a broad knowledge of

endocrine and fertility problems in female and male patients. They must be clinically

competent in reproductive endocrinology and the surgery relevant to fertility in these

disorders. They must be involved in basic and applied investigation in reproductive

endocrinology and must be able to provide a consultancy service to other obstetricians/

gynecologists.

The following advanced knowledge and skill must be acquired :-

a) an advanced understanding of :-

1. basic endocrine physiology, pharmacology of substances that regulate the

reproductive systems and the relevant aspects of the thyroid and adrenal systems.

2. the endocrine dynamics of pregnancy and the menstrual cycle.

3. the physiology of conception and reproductive tracts related to fertility and

reproduction, aspects of embryology and the techniques of in vitro fertilization

4. immunology and genetics related to reproduction.

5. psychosomatic aspects of reproductive endocrinology.

b) basic knowledge of :-

1. clinical pharmacology of hormones.

2. gross and microscopic pathology relating to reproductive medicine.

3. Good clinical practice in reproductive medicine

c) the capacity to interpret, perform and/or supervise endocrine laboratory diagnostic

procedures with the relevant statistical methodology. This includes a module of laboratory

training with personal involvement in an established assay and in the development of a new

assay.

d) clinical competence in the management of endocrine and fertility problems including : -

1. diagnosis of pituitary, central nervous system, thyroid and adrenal disease relating to

reproduction.

2. diagnosis and management of reproductive organs disease related to reproduction.

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II. Purposes

The purposes of the curriculum are :-

1) to improve knowledge, practice, teaching and research in reproductive medicine.

2) to promote the concentration of very specialized expertise, special facilities and

clinical material that will be of considerable benefit to patients.

3) to establish a close understanding and working relationship with other disciplines

involved in each of the subspecialty fields.

4) to encourage co-ordinated network of relevant clinical services throughout various

regions in Thailand.

5) to accept a major regional responsibility for highter training, research and audit in the

subspecialty fields.

6) to improve the recruitment of talented graduates into the recognized subspecialties

and into the specialty of obstetrics and gynecology as a whole.

III. Educational Objectives

The trainee is determined to

1. be able to evaluate clinically and manage patients with problems related to the

clinical pharmacology of hormones as related to reproductive medicine.

2. have a knowledge of gross, miscroscopic histology, and immunohistochemical

technics as they relate to the diagnosis and further clarification of reproductive

endocrine pathology.

3. be able to evaluate, diagnose and manage patients with infertility and endocrinologic

diseases of immunologic origin.

4. be able to diagnose and manage patients with congenital abnormalities of the female

internal and external genitalia.

5. be able to interpret pedigree data and care for patients with inherited and sporadic

genetic disorders affecting the male and female reproductive system.

6. be able to take a comprehensive medical history, perform a general physical

examination in addition to a specific gynecologic history and physical examination ;

be able to select, organize, accomplish and interpret the diagnostic techniques

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needed to establish a diagnosis, evaluate co-existing diseases or factors which may

have a bearing on selection of and response to treatment, and evaluate the response

to therapy.

7. be able to discuss neuroendocrine physiology and function and to diagnose and

manage patients with diseases originating in the neuroendocrinologic system.

8. be able to discuss ovarian physiologic processes including folliculogenesis,

ovulation, corpus luteum development, maintenance and regression and

steroidogenesis and to diagnose and manage patients with disease involving in

these systems.

9. be able to discuss thyroid function and physiology and be able to diagnose and treat

patients with thyroid disorders.

10. be able to discuss adrenal function and physiology and be able to diagnose and

treat patients with adrenal disorders.

11. be able to discuss and be able to diagnose and treat patients with androgen

disorders.

12. be able to discuss the problems of and to diagnose and manage patients with

disorder of menstruation.

13. be able to diagnose and treat patients with amenorrhea.

14. be able to diagnose and treat patients with endocrine deficiency states.

15. be able to discuss the physiology of growth and development as it relates to normal

puberty, recognize deviations from normal, develop a plan for differential diagnosis

and treat patients with abnormal pubertal development.

16. be able to discuss the problems, diagnose and manage patients during the

menopausal periold.

17. 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.

18. be able to evaluate the male partner and diagnose relative and absolute infertility,

evaluate and manage patients with these problems.

19. be able to discuss the psychosexual aspects of reproductive medicine.

20. be able to discuss the indications for, identify results and perform surgical

procedures appropriate to reproductive endocrinology.

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21. be able to discuss maternal and fetal physiology and pathophysiology and diagnose

and manage endocrinopathy in obstetrical patients.

22. be familiar with methods of contraception, and be able to select the most appropriate

method for a high risk patient and induced abortion.

23. understand the principles of (IVF) in-vitro fertilization and other assisted reproductive

techniques (ART)

24. be able to discuss the nature, application, limitation, interpretation and methodology

of :

24.1 routine semen analysis and computer assisted semen analysis.

24.2 hormone assays in reproductive endocrinology.

24.3 basic laboratory procedures related to assisted reproductive technologies.

25. be able to participate fully in the theoretical and technical aspects of clinical and/or

basic science research projects.

26. be able to participate and be responsible for teaching in reproduction health.

27. be able to discuss and have knowledge of ethical and legal aspects of reproductive

medicine.

28. be given some administrative experience and responsibility.

IV. Contents

1) Clinical pharmacology of hormones 1.1) absorption, excretion, distribution and biotransformation of drugs and

hormones, showing knowledge of these mechanisms for transferring

across membranes (e.g. placenta) and into breast milk, into and across

cells, storage, metabolism, enzyme systems, renal, hepatic and fecal

excretion.

1.2) Mechanisms of drug and hormone action including structure-activity

relationships, receptors and sites of action.

1.3) Drug and hormone effects, including dose-response, biological variations,

spectrum of effects and factors that modify effects (e.g. age, sex, body

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weight, route of administration, tolerance and drug or hormonal

interactions), teratogenicity, agonist and antagonist.

1.4) Drug toxicity and hormone reaction to allergy, teratogenicity, dependence

and addiction.

1.5) Governmental and pharmaceutical regulations pertaining to drugs and

hormones and their development.

1.6) Design and analysis of clinical trials.

2) Pathology 2.1) vagina :

2.1.1 the gross and microscopic findings of endometriosis and

adenomyosis.

2.1.2 the pathophysiology and possible consequences of antenatal

hormone exposure.

2.1.3 the mechanisms of action and effects of various hormones upon the

vagina.

2.2) cervix :

2.2.1 the mechanisms of action and effects of hormones upon the cervix.

2.2.2 the pathophysiology and possible sequences of antenatal hormone

exposure.

2.2.3 the gross and microscopic findings of the cervix under condition of

human papilloma virus (HPV), chlamydial, and other infections.

2.3) endometrium :

2.3.1 histological preparations of normal and abnormal endometrium.

2.3.2 the current data relating estrogen with endometrial hyperplasia and

adenocarcinoma.

2.3.3 developmental stages of the endometrium (dating).

2.3.4 implantation, the placenta and uterus in early pregnancy.

2.4) myometrium :

2.4.1 the gross and microscopic findings of adenomyosis, leiomyoma and

other myometrial lesions related to reproductive endocrinology.

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2.4.2 the relationships of leiomyoma to infertility including each of the

different types (e.g.subserous, intramural and submucous).

2.5) oviduct :

2.5.1 the gross and microscopic findings of diseases of the oviduct related

to reproductive endocrinology (e.g. acute and chronic salpingitis,

granulomatous salpingitis, endometriosis).

2.5.2 the natural history and clinical course of acute and chronic salpingitis

and relate these to subsequent fertility.

2.6) ovary :

2.6.1 the gross and microscopic findings and describe the natural history

of ovarian tumours related to reproductive endocrinology (e.g.

follicular cysts, luteoma, corpus luteum, polycystic ovarian syndrome,

endometrioma, granulose-theca cell tumour, Sertoli-Leydig cell

tumour, gynandroblastoma, cystic teratoma, dysgerminoma,

gonadoblastoma and mixed germ cell or gonadal tumours).

2.6.2 the different compartments of the Graafian follicle (e.g. granulose

cells, theca and adjacent stroma) and the primordial, preantral, antral

and Graafian follicles, including the dynamic changes which occur in

the ovary from embryo to menopause.

2.6.3 specific staining technics and cellular ultrastructure as related to

function.

2.6.4 the gross and microscopic findings and the development of gonadal

structures found in various forms of gonadal dysgenesis and intersex

conditions.

2.7) hypothalamus ; CNS :

2.7.1 the function and relationships of the various hypothalamic centers

involved in reproductive endocrine function.

2.7.2 other endocrinologically related central nervous system structures

(e.g. third ventricle, highter centers).

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2.8) pituitary :

2.8.1 cellular morphology of normal and neoplastic cells of the

adenohypophysis.

2.8.2 cellular function of the neurohypophysis.

2.9) testis :

2.9.1 the various stages of normal and abnormal spermatogenesis.

2.9.2 the gross and microscopic findings in testicular disease.

2.10) thyroid / adrenal :

2.10.1 the normal thyroid structures and the various thyroid lesions

associated with altered reproductive endocrine function (e.g.

Graves disease, thyroiditis, neoplasia).

2.10.2 the normal adrenal structures and the various adrenal lesions

associated with altered reproductive endocrine functions (e.g.

hyperplasia, adenoma, carcinoma, pheochromocytoma).

3) Immunology 3.1) the essentials of basic immunology.

3.2) the usefulness and limitations of immunological tests in infertility.

3.3) the pathophysiology of autoimmune disease to gonadal failure and other

primary endocrine dysfunction, including the autoimmune aspects of

gonadal dysgenesis.

3.4) the developing knowledge of immunology to contraception.

3.5) the effect of active and passive immunization upon changes in hormone-

specific target tissues.

3.6) the clinical features and interactions of autoimmune endocrinological

diseases (e.g. of thyroid, adrenal, gonad).

4) Embryology 4.1) the embryonic development of the genital tract including the factors

controlling male and female development of the gonadal primordial, internal

duct system and external genitalia.

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4.2) developmental abnormalities of the genital tract including ambiguous

gentalia, imperforate hymen and vaginal septa, uterine anomalies, Mullerian

agenesis and gonadal dysgenesis

4.3) the embryology of the hypothalamic-pituitary and other pertinent endocrine

systems.

4.4) the embryology of the urological system.

4.5) the various stages of oocyte and sperm maturation and fertilization.

4.6) the pre-implantation development of the human embryo in vitro and in vivo.

5) Genetics 5.1) normal genetics (e.g. Mendelian inheritance, the structure and identification

of chromosomes and gametogenesis).

5.2) abnormal genetics including chromosome abnormalities and genetically

transmitted abnormalities of sexual development (e.g. hermaphroditism).

5.3) inherited, non-reproductive disorders referable to reproductive medicine

(e.g. congenital adrenal hyperplasia, diabetes mellitus).

5.4) genetic studies including pedigree, karyotype analysis, antenatal diagnosis

of genetic disease, and including use of gene probes and associated

technics.

5.5) infertility and early pregnancy loss.

5.6) indications and arrangements for specialized genetic diagnosis and

counseling.

5.7) genetic aspects of artificial inseminaton.

5.8) preimplantation genetic diagnosis.

6) Clinical diagnostic techniques 6.1) operative procedures : including biopsies of the vagina, cervix and

endometrium, cytological studies, laparoscopy with dye instillation and

laparoscopic biopsy, laparotomy with biopsy, diagnostic laparoscopy,

hysteroscopy and other intraabdominal diagnostic techniques.

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6.2) imaging including hysterosalpingography, sella turcica radiography,

arteriography, computerized tomography, arterial catheterization, digital

subtraction angiography, venous catheterization, intravenous and

retrograde urography and isotope imaging methods, nuclear magnetic

resonance, bone densitometry.

6.3) endocrinological measurement of hormonal substances in biological fluids

for evaluation of the various endocrine systems including the hypothalamus,

pituitary, parathyroid, thyroid, adrenal gonadal systems and pregnancy and

also be able to perform and interpret dynamic endocrinological testing of

these systems.

6.4) techniques including visual field examination, chromosomal studies and

karyotyping.

6.5) ultrasound of the ovaries and the uterus during menstrual cycle, hormonal

stimulation and in early pregnancy.

6.6) risks and limitations of procedures, diagnosis and evaluation of diagnostic

procedures, understanding the validity of diagnostic tests, variability and

reliability criterias.

6.7) clinical record keeping and data storage including use of photography.

7) Neuroendocrine function and disease states 7.1) anatomical-functional aspects of the hypothalamus, neurovascular

relationships and target cells of the pituitary.

7.2) suprahypothalamic structures and neuronal systems relevant to regulation

of reproductive processes.

7.3) control of secretory activities of the pituitary hormones, including long and

short term rhythms, and their target organs and feedback systems.

7.4) biochemical basis of the neuroendocrine interactions and the use of

neuropharmocological agents.

7.5) anatomical and functional aspects of the peptidergic and

catecholaminergic system and their control of the pituitary hormone

secretion.

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7.6) the site of production, biological action and control of secretion of oxytocin,

vasopressin and neurophysins.

7.7) distribution and cellular characteristics of pituitary homone producting cells

with special reference to gonadotrophe and lactotrophe.

7.8) anatomical arrangement of hypothalamic-hypophyseal portal circulation.

7.9) structure and function of pituitary reproductive hormones and

neuropeptides.

7.10) the pineal gland : the blood brain barrier.

7.11) sex steroid concentrating neurones.

7.12) biochemical basis of neuropharmocology of agonists and antagonists.

Euro-endocrine regulation of the menstrual cycle.

7.13) neuroendocrine function of the fetus and placenta.

7.14) hypothalamic and pituitary hypopituitarism and disorders of over secretion

of pituitary hormones.

7.15) organic lesions and/ or functional disorders of the hypothalamic-pituitary

system.

7.16) ectopic hormone syndromes.

8) Ovarian function and disease states 8.1) hypothalamic-pituitary control of the ovarian cycle.

8.2) cyclic changes in endocrine activities within the ovary.

8.3) synthesis and secretion of hormone substances by the various

compartments and cell types of the ovary. Intra and extra ovarian control

mechanisms.

8.4) mechanism of protein/steroid hormone action in the ovary.

8.5) atresia and selection of the dominant follicle.

8.6) regulation of hormone receptors.

8.7) luteolysis.

8.8) age-related changes in ovarian structure and function.

8.9) ovarian activity during gestation.

8.10) hormone producing tumours of the ovary.

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8.11) clinical and pathophysiological correlates of disorders of the human ovary

(structure and function).

9) Thyroid function and disease states 9.1) TRH-TSH-thyroid physiology.

9.2) the diagnostic value of TSH, thyroid hormones total and free, thyroid

stimulating immunoglobulins and related diagnostic tests.

9.3) the biosynthesis, control and metabolism of thyroid hormones.

9.4) the clinical and pathophysiological correlates of hypo and hyperthyroidism,

particularly related to menstrual disorders and fertility.

9.5) pregnancy and hormone induced changes of thyroid function in the mother

and the effect of abnormal maternal thyroid function on the fetus.

9.6) thyroid physiology in the newborn, identification of cases at high risk of

neonatal thyrotoxicosis and hyperthyroid

9.7) the effects of thyroid replacement and anti-thyroid drug therapy on the

fetus.

9.8) pathophysiology of thyroiditis.

9.9) thyroid function in struma ovarii, molar pregnancy and choriocarcinoma.

9.10) the therapy of hyperthyroidism.

9.11) pharmacology of thyroid medications.

10) Adrenal function and disease states 10.1) regulation and secretion of adrenocortical functions.

10.2) clinical and laboratory assessment of adrenocortical function.

10.3) pharmacology of naturally occurring and synthetic glucocorticoids and

mineralocorticoid.

10.4) adrenocortical hypo-and hyperactivity (e.g. Cushing?s hyperplasia,

adenoma, carcinoma).

10.5) congenital adrenal hyperplasia (see Genetics).

10.6) effects of aberrations of adrenocortical function on hypothalamic-pituitary-

ovarian function, including Nelson?s syndrome.

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10.7) aldosterone and disorders of the rennin-angiotensin system.

10.8) catecholamine disorders.

11) Androgen disorders 11.1) production, physiology and metabolism of androgens in normal women

and the mechanisms of action of androgen.

11.2) the symptoms and signs of androgen excess together with any causes

based on pathophysiology of androgen excess.

11.3) the physiology of normal and abnormal hair growth.

11.4) ovarian tumors, benign and malignant, which secrete androgens.

11.5) those benign stromal changes in the ovary which may result in increased

androgen production.

11.6) polycystic ovarian syndrome and abnormal hormone production

11.7) congenital and acquired adrenal hyperplasia in terms of etiology, genital

morphology, general metabolic effects and treatment.

11.8) the management of androgen excess and hirsutism.

11.9) the pharmacology of anti-androgens.

11.10) androgen production and its control in the testis.

12) Disorders of menstruation 12.1) endocrine criteria of the normal menstrual cycle, the effects of sex steroids

on the endometrium.

12.2) the effects of steroids in relation to proliferation of the endometrium,

secretory changes, and menstruation, including spiral arteriolar change,

lysosome stability and fibrinolysis.

12.3) the physiology of menstruation.

12.4) the pathophysiology of disorders of menstruation including dysfunctional

uterine bleeding (DUB)

12.5) anovulation and the resultant hormonal change syndicating any effect on

the endometrium, including endometrial hyperplasia.

12.6) methods of quantitating menstrual blood loss.

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12.7) methods of evaluation of abnormal uterine bleeding.

12.8) the medical and surgical treatment of patients with abnormal uterine

bleeding especially DUB.

12.9) non-gynecological causes of abnormal bleeding (e.g. hypothyroidism,

blood dyscrasias and anticoagulants).

13) Amenorrhea 13.1) the pathophysiology of primary and secondary amenorrhea, including

nutritional and psychological aspects.

13.2) structural abnormalities of the genital tract associated with amenorrhea.

13.3) amenorrhea in relation to puberty and menarche.

13.4) the clinical manifestations of conditions associated with amenorrhea (e.g.

polycystic ovarian syndrome, hypopituitarism, gonadal dysgenesis).

13.5) the physiology and pathophysiology of prolactin secretion, the

management of patients with inappropriate prolactin secretion.

13.6) the technics for the evaluation and therapy of patients who require

ovulation induction.

13.7) the interpretation of tests used to evaluate amenorrhea.

13.8) a rational diagnostic and therapeutic approach to patients with

amenorrhea.

13.9) the treatment options for young women with ovarian failure, with particular

regard to future fertility.

14) Endocrine deficiency states 14.1) deficiencies of the hypothalamic-pituitary system (e.g. hypothalamic or

pituitary deficiency).

14.2) deficiencies of the thyroid including hypothyroidism in pregnant or non-

pregnant women and women on various hormonal medications including

the differentiation of hypothyroidism resulting from thyroid, pituitary or

hypothalamic disease.

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14.3) deficiencies of the adrenal, including hypoadrenalism resulting from

pituitary or adrenal diseases or hormonal medications in pregnant or non-

pregnant women.

14.4) the management of patients during the perimenopause and menopause.

The various therapies for such patients and the pharmacology of sex

hormonal preparations.

14.5) receptor and enzyme abnormalities (e.g. androgen resistant states).

15) Puberty 15.1) the normal sequence of pubertal changes in the female and male and their

chronology.

15.2) the effects of hormones on bone growth and epiphyseal closure.

15.3) the hormonal changes and gametogenesis relative to the reproductive

cycle from intrauterine life to the development of normal reproductive

cycles (e.g. gonadotrophin secretion in the fetus and the neonate),

sensitivity of the feedback system during fetal and neonatal life and

childhood, the role of adrenal androgens).

15.4) delayed puberty indicating the differential diagnosis evaluation,

appropriate therapy, and counseling.

15.5) sexual precocity indicating the differential diagnosis, evaluation,

appropriate therapy, and counseling.

16) Menopause 16.1) the epidemiology and physiology of the menopause.

16.2) all aspects of the menopause.

16.3) counseling to each individual and general public.

16.4) Topics of

- Short-term consequence

- Vasomotor Symptoms

- Urogenital Symptoms

- Sexual problems

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- Skin problems

- Long-term consequence

- Osteoporosis

- Cardiovascular disease

- Skin problem

16.5) proper various therapies for normal and complicated menopausal women.

16.6) side effects of HRT.

17) Female infertility 17.1) an appropriate history and a physical examination oriented to infertility.

17.2) evaluation of an infertile female.

17.3) the overall management of the infertile couple, knowledge related to :

17.3.1 Ovulatory disorders, including : correct utilization and

interpretation of basal body temperatures, plasma progesterone

and endometrial biopsy, diagnoses of causes of anovulation

including polycystic ovarian syndrome, syndromes of

inappropriate prolactin secretion, CNS-hypothalamic-pituitary

syndromes and other causes, selection of ovulation induction

utilizing clomipherne, human gonadotropin, bromocryptine and

other agents, appropriate monitoring of ovulation induction

including estrogen determinations, ultrasound, LHRH and other

agents.

17.3.2 Tubal disorders, including : correct utilization and interpretation

of studies of tubal function (e.g. hysterosalpingography and

laparoscopy). Indications for tubal reparative procedures

including the specific indications for microsurgery and laser

surgery.

17.3.3 Uterine factors, including: correct utilization and interpretation of

studies of the uterine cavity, such as hysterogram and

hysteroscopy and indications for corrective procedures.

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17.3.4 Endometriosis and other peritoneal diseases, including :

diagnosis and staging of endometriosis and other peritoneal

causes of infertility, knowledge of the medical management of

endometriosis (i.e. pseudopregnancy, danazol, continuous

progesting, androgen therapy, and GnRH analog), indications for

surgery for these diseases, the rationale for pharmacologic

adjuncts to surgical therapy.

17.3.5 Cervical factors, including : the several causes of cervical

infertility (e.g. chronic cervicitis, inadequate mucus production

and cervical antibody formation), utilization and interpretation of

the various tests of cervical mucus-sperm interaction : application

of current therapeutics (e.g. estrogen, antibiotic, cryosurgery,

condom therapy, artificial insemination-homologous and

heterologous).

17.3.6 Artificial insemination (homologous and heterologous

techniques), including: the indications and contraindications, the

evaluation of the male partner in infertility, proper screening of

donors to exclude genetic disorders and transmissible infection,

including HIV.

17.3.7 Adoption, including : the indications for adoption, knowledge of

appropriate counseling methods, familiarity with various local

agencies and legal implications dealing with adoption.

17.3.8 In vitro fertilization/embryo transfer, including : indications,

techniques, and limitations. Awareness of current developments

with this and related techniques of assisted reproduction.

17.3.9 Outcome of various managements, including : the statistics

related to outcome of various modalities of management of

causes for infertility. Include life table analyses.

17.3.10 Unexplained infertility, including : knowledge and evaluation of

current methods of diagnosis and therapy.

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17.4) the incidence of infertility as related to age and the prognosis for

treatment of infertility.

18) Male infertility 18.1) an appropriate history and a physical examination oriented to infertility.

18.2) evaluation of an infertile male.

18.3) Topics of

18.3.1 The cycle of spermatogenesis, including endocrinologic control,

mechanisms and its abnormalities.

18.3.2 The formation and content of seminal fluid.

18.3.3 The physiology and pathophysiology of ejaculation, including

diseases which inhibit it.

18.3.4 Abnormalities in sperm transport including ductal obstruction and

retrograde ejaculation

18.3.5 The medical and surgical therapies of male infertility.

18.3.6 The biosynthesis of estrogen, androgen and progestin by the

human testis and the biological action of testosterone in man.

18.3.7 Sperm banking. Cryobiology of semen.

18.3.8 Methods of evaluating semen quality and fertilizing capabilities.

18.3.9 Environmental factors, including drugs that may affect the

endocrine and exocrine function of the testis.

18.3.10 Sperm preparation techniques.

19) Psychosexual aspects of reproductive medicine 19.1) the psychodynamics of growth and development, puberty and the

establishment of the gender role.

19.2) antenatal hormone influence on subsequent behaviour and psychological

function.

19.3) psychological factors in amenorrheoa

19.4) the psychological changes associated with treatment of infertility.

19.5) the psychological changes associated with hormonal therapy.

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19.6) the psychological and endocrine factors associated with the

premenstrual syndrome.

19.7) the psychological and endocrine factors associated with the menopause.

19.8) the effects of infertility upon the family.

19.9) the general concepts of normal and abnormal sexual function and

gender and awareness of local facilities for counseling.

20) Surgical techniques 20.1) fertility control : including laparoscopy and laparotomy techniques.

Reversal of sterilization.

20.2) diagnostic techniques : including hysterosalpingography and

Endoscopy.

20.3) infertility surgery : including

20.3.1 uterus-reconstruction of bicornuate or septate uterus,

myomectomy, lysis of uterine synechiae.

20.3.2 tube-reparative techniques ofr tubal and /or adhesive pelvic

disease.

20.3.3 ovaries ; wedge resection, cystectomy.

20.3.4 endometriosis ; staging, surgical therapy.

20.4) the role of endoscopic surgery in the treatment of the above conditions.

20.5) developmental disorder : including those of

20.5.1 vagino-vaginal reconstruction by dilatation or surgery, imperforate

hymen, vaginal septa.

20.5.2 uterus- Mullerian anomalies with obstruction of drainage.

20.6) ambiguous genitalia : including involvement in the assignment of sex of

rearing for an infant with ambiguous genitalia, techniques for surgical

construction of unambiguous functioning female external genitalia and

vagina (e.g. vaginoplasty, clitoridectomy and clitoral resection),

indications and techniques for gonadectomy.

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20.7) complications : including the incidence and the preventive and other

therapeutic measures for immediate and late complications of

reproductive and infertility surgery.

21) Endocrinology of pregnancy 21.1) the feto-placental unit as it relates to the physiology and pathophysiology

of steroid hormones (e.g. estrogen, progestogen, corticosteroids).

21.2) the physiology of deciduas-chorionic-placental peptide hormones (e.g.,

gonadotrophins, somatomammotrophin, thyrotropin, ACTH/opioid

peptides and prolactin).

21.3) the initiation of parturition including physiology, pathophysiology and

pharmacology of prostaglandins.

21.4) the physiology of fetal adrenal glands.

21.5) the endocrine pathophysiology of the preeclampsia and eclampsia

including the possible roles of rennin, angiotensin, aldosterone and

prostaglandins (refer to fetal medicine)

21.6) the physiology and pathophysiology of fetal hypothalamic pituitary

gonadal function and pancreatic function.

21.7) the pathophysiology of altered maternal thyroid, adrenal and pancreatic

status during pregnancy.

22) Family planning and reproductive tract infection 22.1) the pharmacodynamics, metabolic effects and complications of the

various oral, injectable and implantable contraceptive preparations.

22.2) the mechanism of action and complications in intrauterine contraceptive

devices (e.g. inert, copper and progestogen containing).

22.3) the indications, advantages, disadvantages, side effects, complications,

and efficacy of traditional contraceptive methods (e.g. barrier, vaginal

spermicide and periodic abstinence) as compared to non-utilization of

contraceptives.

22.4) male contraception and sterilization.

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22.5) female sterilization.

22.6) interruption of pregnancy, including : techniques of estimation of

gestational age. The various techniques of pregnancy interruption (e.g.

postcoital contraception, menstrual extraction, medically induced

methods, dilatation and evacuation, mid trimester abortion with

prostaglandins and other agents). And details of the possible hazards

and long-term fertility complications of such procedures.

22.7) potential techniques applicable to male and female contraception

indicating any appropriate findings.

22.8) counseling techniques in family planning and reproductive tract infection.

22.9) HIV infection in Reproductive Medicine.

22.10) Management of contraceptive complications

23) Techniques of assisted reproduction 23.1) the facilities and personnel required for such a program

23.2) mechanism controlling oocyte development and maturation. The

appearance of the mature compared with an immature oocyte.

23.3) indication and contraindication of ART

23.4) methodology for inducing of preovulatory follicles and describe methods

for monitoring follicular development.

23.5) methods for oocyte retrieval, including ultrasound guided transvaginal

oocyte recovery, sperm retrieval techniques including PESA, MESA,

TESA.

23.6) techniques for extracorporeal fertilization and in-vitro growth of embryos.

23.7) the technique of embryo transfer.

23.8) the selection of patients for IVF, and gamete intra-fallopian tube transfer

(GIFT) and the expected results.

23.9) techniques for preservation of embryos.

23.10) the ethical consideration of ART.

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24) Laboratory capability 24.1) specific techniques for hormone assays (e.g. steroids, proteins

receptors).

24.2) assay validation and description of standard curve, precision, specificity,

bias, sensitivity, and assay drift.

24.3) biochemical methodology including extraction, purification and

identification of steroid and protein hormones.

24.4) enzyme kinetics as they relate to steroid and protein metabolism.

24.5) kinetics of production, distribution, interconversion and metabolism of

specific hormones.

24.6) basic molecular biology technics including oligonucleotide probes, in situ

hybridization, Southern, Western and Northern blotting, restriction

fragment length polymorphism (RFLP), polymerase chain reaction (PCR).

24.7) national and international regulations related to laboratory safety, animal

and human experimentation, radiation hazards, quality control, etc.

24.8) routine semen analysis as recommended by the World Health

Organization and computer assisted semen analysis (CASA).

24.9) sperm washing techniques : swim-up, percoll gradients.

24.10) sperm function tests : hypoosmotic swelling test, sperm cervical mucus

interaction, assay for sperm antibodies, hamster egg penetration assay

etc.

24.11) basic IVF laboratory technics : oocyte identification and grading, oocyte

culture and insemination, identification and grading of early embryo,

preparation of media for IVF, basic tissue culture technics, assisted

fertilization techniques including ICSI.

24.12) experimental design, data interpretation and statistical analysis

25) Research and thesis 25.1) Topics of

25.1.1 epidemiological techniques (e.g. cohort studies and case control

studies, cumulative rate calculation and assessment of bias).

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25.1.2 population parameters and sampling techniques.

25.1.3 measures of comparisons of means and variations.

25.1.4 analysis of

25.1.4.1 the question examined

25.1.4.2 the hypothesis

25.1.4.3 the sampling technique (including sampling bias and

sample size).

25.1.4.4 the expression and correlation of raw data.

25.1.4.5 the selection and application of appropriate statistical

tests

25.1.4.6 significance of the results.

25.1.4.7 the conclusions.

25.1.4.8 the appropriate reference which can be obtained.

25.1.5) application of the following statistical tests :

25.1.5.1 parametric tests such as unpaired, paired t-tests and

chi-square.

25.1.5.2 non-parametric tests.

25.1.5.3 correlation and regression.

25.1.6) definition of the terms significance, confidence interval, type I

error and type II error.

25.1.7) statistical analysis of assay data and evaluation of quality control.

25.1.8) the value of discussion and collaboration with the Department of

Biostatistics.

25.2) Topics of

25.2.1 experimental design (e.g. laboratory, epidemiology).

25.2.2 data acquisition, storages, interpretation and statistical analysis.

26) Teaching 26.1) some responsibility for teaching junior staff in reproductive medicine.

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26.2) full participation in the unit?s postgraduate program, with some

administrative responsibility for the organization of teaching in

reproductive medicine.

26.3) participation in the undergraduate teaching program.

27) Ethical and legal aspects 27.1) legislation, particularly recent, relevant to clinical practice.

27.2) in vitro fertilization and embryo transfer.

27.3) gamete storage and donation.

27.4) surrogacy.

27.5) fertility control.

28) Administrative experience Some administrative responsibility which will allow the development of skills

relevant to the future provision and organization of clinical services.

V. Learning Experience (Training Program)

The training program in reproductive medicine is two years in duration.

The first year is devoted to the development of clinical expertise and skill in the field of

reproductive medicine. The trainee will spend 6 months in the reproductive endocrinology,

menopause, and infertility clinic to see and evaluate patients who are referred with

gynecological endocrinologic problems or infertility. The third quarter will be spent in

gynecologic pathology and surgery, learning the techniques of laparoscopy, hysteroscopy,

tubal microsurgery and other reproductive surgery. The trainee is expected to review not only

gross but also microscopic pathology at the time of surgery on all surgical cases in which the

trainee participates. The fourth quarter will be spent in general endocrinology and genetics. The

training in general endocrinology will include rotations through the diabetes, thyroid, pituitary,

and adrenal clinics. This quarter also includes an assignment to medical genetics where the

trainee will participate in clinical as well as didactic training in medical genetics.

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In the second year, the trainee will spend 3 months in the family planning and

menopause clinic to see and manage patients who seek advice in fertility control. An elective

period of 3 months is provided for trainee to avail himself more deeply in the field of their own

interest such as clinical pharmacology, advanced immunology, reproductive physiology,

embryology, genetics, urology, or clinical imaging technics etc. The last 6 months will be spent

entirely in the laboratory, where the trainee will have a chance to learn basic laboratory technics

such as semen analysis, hormonal assays, sperm washing, sperm penetration test and other

related technics. During the two year program, the trainee will be encouraged to participate in

one or more research projects related to reproductive medicine.

Throughout the program, the fellow will be required to organize reproductive medicine

conferences, teach residents and medical students and complete at least one research paper

acceptable for publication in a medical journal or for presentation in national/ international

congress in reproductive medicine.

Month

Year 1-3 4-6 7-9 10-12

Reproductive

Endocrine,

Menopause,

Infertility Clinic, &

Sexual health

Clinical Core

Curriculum

(Clinical Tech.)

Gyn. Surgery and

Pathology.

Clinical Core

Curriculum (Surg.

Tech.)

Reproductive

Endocrine,

Menopause,

Infertility Clinic,

Family planning &

Sexual health

Didactic Core

Curriculum

General Endocrine

Clinic. Didactic Core

Curriculum

1

Reproductive Endocrine, Menopause, Family Planning & Infertility Seminars

Family Planning

Clinic

Elective Laboratory techniques 2

Research project in reproductive medicine

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VI. Evaluation

1. Formative evaluation

The assessment will be arranged by the training institute once a year. The

examinations comprise of multiple choice questions (MCQs), multiple essay questions (MEQs),

essay, and oral examination. Clinical and surgical skills, and attitude are evaluated by

observation. When the trainee is clinically competent and has acceptable attitude in

reproductive medicine, assessed by the reproductive medicine staffs, he or she will be eligible

for summative evalutation.

2. Summative evaluation

The Royal Thai College of Obstetricians and Gynecologists will conduct the

Examinations.

VII. Requirements for Trainees. To be eligible for subspecialty training in reproductive medicine a trainee have to :-

1. be an active member of The Royal Thai College of Obstetricians and Gynaecologists.

2. have a valid medical license in Thailand.

VIII. Staffs

1. Sopon Cheewadhanaraks, Assistant Professor, MD, Dip Thai Board of Obstetrics and

Gynecology, Fellowship in Reproductive Biology, Royal Women Hospital, Melbourne,

Australia, Dip Thai Board of Reproductive Medicine, Program Director

2. Sutham Pinjaroen, Assistant Professor, MD, Dip Thai Board of Obstetrics and

Gynecology, Dip in Epidemiology and Applied Statistics, Chinese University of

Hong Kong, Dip Thai Board of Reproductive Medicine

3. Verapol Chandeying, Associate Professor, MD, Dip Thai Board of Obstetrics and

Gynecology

4. Hatern Tintara, Associate Professor, MD, Dip Thai Board of Obstetrics and

Gynecology, Certificate in shortcourse training of LAVH and Laparoscopic surgery,

Arizona, USA.

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5. Chatpavit Getpook, Assistant Professor, MD, Dip Thai Board of Obstetrics and

Gynecology, M. Med. Sci. in Assisted Reproduction, Univ. of Nottingham, UK.

6. Karanrat Soonthornpun, Assistant Professor, MD, Dip Thai Board of Obstetrics and

Gynecology

7. Saranya Wattanakumtornkul, MD, Dip Thai Board of Obstetrics and Gynecology,

Certificate in Reproductive Endocrinology and Infertility, Washing University, School

of Medicine, St. Louis, Missouri, USA, Certificate in Reproductive Endocrinology and

Infertility, Mayo Clinic, Rochester, Minnesota, USA.

8. Krantarat Peeyananjarassri, MD, Dip Thai Board of Obstetrics and Gynecology,

Fellowship in Menopause, Sydney Menopause Centre, Royal Hospital for Women

Randwick, New South Wales, Australia.

9. Somchit Jaruratanasirikul, Professor, MD, Dip Thai Board of Pediatrics, Fellowship in

Pediatric Endocrinology.

10. Supamai Soonthornpun, Assistant Professor, MD, Dip Thai Board of Internal

Medicine.

11. Monthira Tanthanuch, Assistant Professor, MD, Dip Thai Board of Urology,

Certificate in Thai Studies.

12. Kobkul Tungsinmunkong, Assistant Professor, MD, Dip Thai Board of Pathology,

Fellowship in Gynecologic Pathology, University of Maryland, USA.

13. Pornprot Limprasert, Assistant Professor, MD, Ph.D. (Human Genetics), American

Board of Medical Genetics (Clinical Molecular Genetics), Research Fellow

(Neurogenetics), Postdoctoral Fellow (Human Molecular Genetics)

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IX. Clinical Workload and Facilities

9.1 Outpatients

Year

2000 2001 2002 2003

Endocrine and Infertile cases (n) 1,368 1,234 1,396 1,522

Menopause (n) 1,920 1,877 1,758 1,523

Family planning (n) 4,897 5,363 4,830 5,255

9.2 ART and Sperm bank

Year

2000 2001 2002 2003

IVF (n) 48 14 29 38

GIFT (n) 7 15 6 9

ART patients with

cryopreserved embryos (n)

15 2 18 23

IUI patients with cryopreserved

sperm (n)

1 2 28 48

9.3 Endoscopic surgery

Year

2000 2001 2002 2003

Operative laparoscopy (n) 36 31 21 52

Operative hysteroscopy (n) 7 2 22 24

Diagnostic laparoscopy (n) 172 158 159

9.4 Tubal microsurgery

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Year

2000 2001 2002 2003

Tubal microsurgery (n) 4 6 10 11