DRCOG – Module 2 – Subfertility – SBA Questions

A 30-year-old woman presents with a 2-year history of primary subfertility. She has cyclical dysmenorrhoea and deep dyspareunia, and at a previous laparoscopy six months ago, she was found to have peritoneal endometriosis with a small amount of adhesions, treated with ablation at the time. She has regular ovulatory cycles confirmed by a mid-luteal progesterone, her partner’s semen analysis is normal, and her ovarian reserve is satisfactory. She asks what her options are. What is the most appropriate management?

A 36-year-old woman with a 4-year history of subfertility due to tubal disease is about to begin IVF. Pelvic imaging confirms bilateral hydrosalpinges. She has a background of extensive previous abdominal surgery with a documented “frozen pelvis” and dense adhesions noted at a previous operation, a BMI of 44 kg/m², and significant cardiorespiratory comorbidity. Her partner’s semen analysis is normal and she ovulates regularly. What is the most appropriate management?

A 33-year-old woman with a 3-year history of primary subfertility is about to begin IVF. Her subfertility is due to tubal disease following previous pelvic inflammatory disease. Hysterosalpingography and pelvic ultrasound confirm bilateral hydrosalpinges, both visible as fluid-filled dilated tubes on transvaginal scan. Her partner’s semen analysis is normal and she ovulates regularly. She is otherwise well, with no significant comorbidity and no contraindication to laparoscopic surgery. What is the most appropriate management?

A 29-year-old woman presents with a 15-month history of primary subfertility. She has oligomenorrhoea progressing to secondary amenorrhoea over the past 6 months, and describes intermittent milky discharge from both breasts. She has no headaches or visual disturbance. She takes no regular medication, and a pregnancy test is negative. Her partner’s semen analysis is normal. Her investigations show:

A mid-luteal progesterone confirms anovulation. MRI of the pituitary shows a 6 mm pituitary microadenoma with no suprasellar extension and no compression of the optic chiasm. What is the most appropriate treatment to restore ovulation?

A 26-year-old woman presents with a 2-year history of primary subfertility and secondary amenorrhoea. She is a competitive long-distance runner with a BMI of 17.5 kg/m². Her partner’s semen analysis is normal. She has no galactorrhoea, no hirsutism and no visual symptoms. Her investigations show:

Pelvic ultrasound shows a normal uterus and ovaries with no polycystic morphology. She has increased her caloric intake and reduced her training, but remains amenorrhoeic and wishes to conceive. What is the most appropriate management?

A 30-year-old woman presents with a 2-year history of primary subfertility. She has regular ovulatory cycles confirmed by a mid-luteal progesterone, her partner’s semen analysis is normal, and hysterosalpingography confirms patent tubes. No cause has been identified, and she has been given a diagnosis of unexplained subfertility. On further questioning she mentions intermittent bloating, loose stools and fatigue, and she has a mild iron-deficiency anaemia. Her BMI is 21 kg/m². Which of the following investigations should be offered?

A 28-year-old woman presents with an 18-month history of primary subfertility. She has regular 28-day ovulatory cycles confirmed by a mid-luteal progesterone, and her partner’s semen analysis is normal. She has no history of pelvic inflammatory disease, no previous ectopic pregnancy, no previous pelvic or abdominal surgery, and no symptoms suggestive of endometriosis (no significant dysmenorrhoea, dyspareunia or cyclical bowel or bladder symptoms). Her BMI is 23 kg/m² and abdominal and pelvic examination is unremarkable. A chlamydia screen is negative. What is the most appropriate first-line investigation to assess her tubal status?

A 29-year-old woman presents with an 18-month history of secondary infertility. She has a child with a previous partner; her current partner has no children. All her investigations are normal. He has had two semen analyses in the last 4 months, both showing oligozoospermia (most recent: volume 1.6 ml, total sperm 6 × 10⁶, concentration 3.2 × 10⁶/ml, total motility 20%, normal forms 3%), with normal endocrine investigations. He asks whether any treatment could improve his semen analysis. What is the most appropriate answer?

A 30-year-old woman presents with secondary infertility. She had a miscarriage 5 years ago and has been trying to conceive since. She has oligomenorrhoea. Early follicular gonadotrophins are normal but, because of her irregular cycles, ovulation could not be demonstrated biochemically. Ultrasound shows a normal-size anteverted uterus and an ovary with more than 20 follicles and an ovarian volume of 11 ml. HyCoSy shows patent tubes. Her BMI is 28 and her partner’s semen analysis is normal. What is the first-line pharmacological treatment?

A 25-year-old woman presents as she and her partner have been trying to conceive for one year without success. Her periods have become increasingly irregular and she has not had a period for the last 4 months. Her BMI is 16 and a urinary pregnancy test is negative. What is the most appropriate next investigation?

A 28-year-old woman and her 32-year-old partner attend the fertility clinic with a three-year history of primary subfertility. Her investigations are all normal. The man’s semen analysis on two occasions 3 months apart shows azoospermia, with FSH 0.2 IU/L, LH 0.1 IU/L and testosterone 8 nmol/L. What is the most appropriate management option?

A 28-year-old woman and her 32-year-old partner attend the fertility clinic with a three-year history of primary subfertility. Her investigations are all normal. The man’s semen analysis on two occasions 3 months apart shows azoospermia, with FSH 0.2 IU/L, LH 0.1 IU/L and testosterone 8 nmol/L. What is the likely diagnosis?

A 28-year-old woman and her 32-year-old partner attend the fertility clinic with a three-year history of primary subfertility. Her investigations are all normal (regular 28-day cycles, ovulatory day-21 progesterone, FSH 6.5 mIU/ml, LH 7.4 IU/L, normal pelvic ultrasound, patent tubes). The man’s semen analysis on two occasions 3 months apart shows azoospermia, with FSH 15.7 IU/L, LH 17.2 IU/L and testosterone 8 nmol/L. What is the likely diagnosis?

A 28-year-old woman and her 32-year-old partner attend the fertility clinic with a three-year history of primary subfertility. Her investigations are all normal (regular 28-day cycles, ovulatory day-21 progesterone, FSH 6.5 mIU/ml, LH 7.4 IU/L, normal pelvic ultrasound, patent tubes). The man’s semen analysis on two occasions 3 months apart shows azoospermia, with FSH 15.7 IU/L, LH 17.2 IU/L and testosterone 8 nmol/L. What is the likely diagnosis?

A 31-year-old woman attends the fertility clinic with her partner. They have been trying to conceive for two years, with no previous pregnancies. Her investigations are normal and her partner’s semen analysis is shown below.

What is the most appropriate next management?

A 31-year-old woman attends the fertility clinic with her partner. They have been trying to conceive for two years, with no previous pregnancies. Her investigations are normal and her partner’s semen analysis is shown below.

What is the most appropriate next management?

What is the recommended frequency of vaginal sexual intercourse to optimise the chance of pregnancy?

Which of the following genetic syndromes is NOT associated with infertility?

A 25-year-old woman presents as she and her partner have been trying to conceive for one year without success. She has a history of ruptured appendicitis as a child but is otherwise fit and well. What is the most appropriate investigation to diagnose the cause of subfertility?

A 25-year-old woman presents to her GP as she and her partner have been trying to conceive for two years without success. What is the approximate incidence of ovulatory factor subfertility?

A 25-year-old woman presents to her GP as she and her partner have been trying to conceive for two years without success. What is the approximate incidence of unexplained subfertility?

A 25-year-old woman presents as she and her partner have been trying to conceive for two years without success. What is the approximate incidence of tubal factor subfertility?

A 25-year-old woman presents as she and her partner have been trying to conceive for two years without success. What is the approximate incidence of male factor subfertility?

A 29-year-old woman with a 3-year history of primary infertility is due to start her first cycle of IVF. She has oligomenorrhoea, a BMI of 24 kg/m², and a diagnosis of polycystic ovary syndrome. Her partner’s semen analysis is normal and hysterosalpingography confirms patent tubes. The clinic is planning her stimulation protocol and wishes to estimate her likely ovarian response.  What is the most appropriate investigation to predict ovarian response prior to IVF?

A 33-year-old woman attends with her partner after 14 months of trying to conceive. She has regular 28-day cycles and a mid-luteal progesterone confirming ovulation. Her partner’s semen analysis is normal. She has read about anti-Müllerian hormone (AMH) online and has paid privately for a test, which reports a low AMH of 4.8 pmol/L. She is very distressed and asks whether this means she will be unable to conceive naturally. How should her AMH result be interpreted?

A 31-year-old man attends the fertility clinic with his partner after 18 months of trying to conceive. He is well, with normal secondary sexual characteristics and normal-sized testes, but on examination the vasa deferentia are impalpable bilaterally. He has no significant past medical history. His partner’s investigations are entirely normal.

Two semen analyses, performed 3 months apart, show consistent results:

Serum FSH, LH and testosterone are all normal. Scrotal ultrasound confirms normal testicular volume with absent vasa with seminal vesicle hypoplasia.

Which investigation is most appropriate to perform next?

A 34-year-old man attends the fertility clinic with his partner after 2 years of trying to conceive. He has normal secondary sexual characteristics, normal-sized testes, palpable vasa deferentia and no varicocele. There is no history of cryptorchidism, mumps orchitis, chemotherapy or testicular trauma. His partner’s investigations are entirely normal.

Two semen analyses, performed 3 months apart, show consistent results:

Serum FSH is elevated, LH is normal and testosterone is normal. Which investigation is most appropriate to perform next?

A 25-year-old woman presents as she and her partner have been trying to conceive for one year without success. Her periods have become increasingly irregular and she has not had a period for the last 4 months. She has noticed worsening headaches and visual disturbances over the last 4 months. Her BMI is 23 and a urinary pregnancy test is negative. What is the most appropriate next investigation?

A 25-year-old woman presents as she and her partner have been trying to conceive for one year without success. Her periods have become increasingly irregular and she has not had a period for the last 4 months. Her BMI is 35 and she has noticed worsening acne, hirsutism and a change in her voice. A urinary pregnancy test is negative. What is the most appropriate next investigation?

A 25-year-old woman presents as she and her partner have been trying to conceive for one year without success. Her periods have become increasingly irregular and she has not had a period for the last 4 months. Her BMI is 35 and she has noticed worsening acne. What is the most appropriate next investigation?

A 30-year-old woman presents as she and her partner have been trying to conceive for two years without success. Her periods are regular with a cycle length of 42 days. On which day of her cycle should mid-luteal progesterone be measured?

A 30-year-old woman presents as she and her partner have been trying to conceive for two years without success. Her periods are regular with a cycle length of 35 days. On which day of her cycle should mid-luteal progesterone be measured?

A 30-year-old woman presents as she and her partner have been trying to conceive for two years without success. Her periods are irregular with a cycle length of 35 to 50 days. Which test is most useful for assessing ovulation?

A 34-year-old woman has been trying to conceive through regular unprotected vaginal intercourse for 10 months when she has a miscarriage at 8 weeks. There is no known cause of infertility. She asks how the miscarriage affects her eligibility for fertility investigations. Which of the following statements is correct?

A 30-year-old woman and her male partner have been trying to conceive through regular unprotected vaginal intercourse for 6 months. She has irregular menstrual cycles lasting 35-45 days and is noted to have hirsutism.  Her partner has no significant medical history. What is the most appropriate action?

A 37-year-old woman and her male partner have been trying to conceive through regular unprotected vaginal intercourse for 6 months. She has regular menstrual cycles and there is no suspected or known clinical cause of infertility. What is the most appropriate action?

A 25-year-old woman presents as she and her partner have been trying to conceive for one year without success. What percentage of couples will conceive after two years of regular unprotected sexual intercourse?

Which of the following genetic syndromes is not associated with infertility?

A 29-year-old woman with polycystic ovary syndrome has been trying to conceive for 12 months without success. She has a BMI of 32 kg/m² and oligomenorrhoea, and investigations confirm anovulatory cycles. Her partner’s semen analysis is normal and her tubal patency has been confirmed. She has been given lifestyle advice and has been working on weight optimisation. She now asks what medical treatment can help her conceive. What is the most appropriate first-line medical treatment to help her conceive?

A couple attend the fertility clinic to discuss IVF. The woman is 38 years old and has a diagnosed cause of infertility (bilateral tubal disease) for which other treatments are not suitable. She has never had IVF before, has a satisfactory ovarian reserve, and meets the relevant access criteria. She asks how many cycles of IVF she should be offered. According to NICE guidance, what should she be offered?

A 40-year-old woman attends the fertility clinic with her partner. They have a 2-year history of subfertility and she is nulliparous. Investigations confirm unexplained subfertility — she has regular ovulatory cycles, patent tubes, satisfactory ovarian reserve, and her partner’s semen analysis is normal. They have completed 2 years of trying to conceive through regular unprotected intercourse. She has never had IVF before and meets the relevant access criteria. She asks how many cycles of IVF she should be offered. According to NICE guidance, what should she be offered?

A couple are undergoing their first cycle of IVF for unexplained subfertility. The woman is 35 years old. They have read online about several “add-on” treatments offered by some private clinics and ask specifically whether pre-implantation genetic testing for aneuploidy (PGT-A) — testing embryos for chromosomal abnormalities before transfer — will increase their chance of having a baby. Neither partner has a known chromosomal abnormality or a heritable single-gene disorder. What is the most appropriate advice?

A 34-year-old woman and her partner attend to discuss NHS-funded IVF. They have a diagnosis of unexplained infertility and have been trying to conceive for 3 years, satisfactory ovarian reserve, and she meets the relevant access criteria. Because of long waiting times, they had already paid privately for 1 full cycle of self-funded IVF, which was unsuccessful. She is now asking whether having self-funded a cycle disqualifies her from NHS-funded treatment, and if not, how many NHS cycles she should be offered. Which of the following statements is correct?

A woman who previously had a successful fresh IVF cycle returns 2 years later for a frozen embryo transfer. While counselling her about the possibility of cycle cancellation, what is the minimum endometrial thickness at which you would recommend embryo transfer can proceed?

A 38-year-old woman is undergoing her first full cycle of IVF for tubal-factor subfertility. Ovarian stimulation and oocyte retrieval have gone well, and the embryology laboratory reports that she has two top-quality blastocysts available for transfer, with others suitable for cryopreservation. She is anxious to maximise her chance of success and asks whether transferring two embryos would be better than one. What is the most appropriate embryo transfer strategy?

A 40-year-old woman is undergoing her first full cycle of IVF using her own eggs for unexplained subfertility. Ovarian stimulation and oocyte retrieval have gone well, and the embryology laboratory reports that she has good-quality embryos available for transfer. She asks how many embryos should be transferred. What is the most appropriate embryo transfer strategy?

A 38-year-old woman with a BMI of 33 kg/m² asks the clinician to estimate her chance of a live birth following IVF. Which of the following is recommended as a predictor of pregnancy and live birth?

A 28-year-old woman with PCOS presents with irregular cycles and infertility for two years. Her BMI is 22 kg/m². Serum LH and testosterone are elevated, and ultrasound shows polycystic ovaries.  She travels abroad frequently for work and would prefer follow-up telemedicine consultations if possible. What is the most appropriate management option?

A 30-year-old woman with PCOS has been on letrozole for six cycles with no evidence of ovulation. She is currently taking metformin concurrently and wishes to continue fertility treatment but does not feel ready to embark upon IVF treatment yet. What is the most appropriate management option?

A 35-year-old woman with a history of irregular cycles and elevated FSH (>30 IU/L) presents with infertility. Anti-Müllerian hormone (AMH) is undetectable. What is the most appropriate management?

A 32-year-old woman presents with secondary amenorrhoea and subfertility of two years duration. Serum prolactin is elevated, and MRI reveals a 5mm pituitary microadenoma. What is the most appropriate management?

A 33 year old woman is seen in fertility clinic.  She is Para 1 having had a previous vaginal birth at term ten years ago with a different partner.  She has been trying to conceive with her new partner for one year.  She has previously had a diagnosis of mild endometriosis at diagnostic laparoscopy four years ago which was performed for pelvic pain symptoms.  Pelvic ultrasound shows normal appearances of the ovaries and uterus.  She has regular periods every 28 days and mid-luteal progesterone confirms ovulation.  FSH and LH levels are normal and AMH levels confirm normal ovarian reserve. Her partner’s semen analysis is within normal limits. What is the most appropriate management?

A 33 year old woman is seen in fertility clinic.  She is Para 1 having had a previous vaginal birth at term ten years ago with a different partner.  She has been trying to conceive with her new partner for four years.  She has previously had a diagnosis of mild endometriosis at diagnostic laparoscopy four years ago which was performed for pelvic pain symptoms.  Pelvic ultrasound shows a left sided ovarian cyst measuring 41x33x28mm, with appearances consistent with an ovarian endometrioma.  She has regular periods every 28 days and mid-luteal progesterone confirms ovulation.  FSH and LH levels are normal and AMH levels confirm normal ovarian reserve.  Her partner’s semen analysis is within normal limits. What is the most appropriate management?

A 36 year old nulliparous woman is seen in fertility clinic.  She has been trying to conceive with her partner for three years and has a history of Stage IV deep infiltrating endometriosis for which she has had two previous laparoscopies. Pelvic ultrasound is suggestive of bilateral hydrosalpinges and hysterosalpingography shows that her fallopian tubes are dilated but patent. She has regular periods every 28 days and mid-luteal progesterone confirms ovulation.  FSH and LH levels are normal and her AMH levels confirm normal ovarian reserve.  Her partner’s semen analysis is within normal limits. What is the most appropriate management?

A 22 year old nulliparous woman is seen in gynaecology clinic following recent surgery six months ago for Stage III endometriosis.  Her symptoms of pelvic pain have greatly improved and she and her partner wish to start a family.  She has been trying to conceive for four months and is anxious that she may need assisted conception due to her diagnosis of endometriosis.  Pelvic ultrasound shows normal appearance of the uterus and ovaries and HSG confirms patent Fallopian tubes. She has regular periods every 28 days and mid-luteal progesterone confirms ovulation.  FSH and LH levels are normal and her AMH level confirms normal ovarian reserve.  Her partner’s semen analysis is within normal limits. What is the most appropriate management?

A 38 year old nulliparous woman is seen in gynaecology clinic following recent surgery six months ago for Stage III endometriosis with extensive excision of deep infiltrating endometriosis and .  Her symptoms of pelvic pain have greatly improved and she and her partner wish to start a family.  She has been trying to conceive for four years and is anxious that she may need assisted conception due to her diagnosis of endometriosis.  Pelvic ultrasound shows normal appearance of the uterus and ovaries and HSG confirms patent Fallopian tubes. She has regular periods every 28 days and mid-luteal progesterone confirms ovulation.  FSH and LH levels are normal and her AMH levels confirm normal ovarian reserve. Her partner’s semen analysis is within normal limits. What is the most appropriate management?

A 27 year old man attends fertility clinic with primary infertility of 3 years duration. His partner is a 28 year old woman and all female fertility investigations have been normal. Semen analysis shows oligospermia. His hormonal profile shows low FSH and LSH levels, low testosterone levels and hyperprolactinaemia. What is the most appropriate management?

A 32-year-old man with a sperm concentration of 8 million/mL, motility 20%, and morphology 2% is diagnosed with oligoasthenoteratozoospermia. He and his partner have been trying to conceive for 2 years without success. What is the most appropriate management?

A 30 year old man is seen in fertility clinic with primary infertility of two years duration. His partner is a 28 year old woman who has a four year old child with a previous partner and all female fertility investigations have been normal. His hormone profile shows very low FSH and LH levels, low testosterone and normal prolactin levels. His semen analysis is as follows:

What is the most appropriate management?

A 35-year-old man is investigated as part of a couple’s subfertility work-up. His partner’s fertility assessment is entirely normal. Two semen analyses performed 3 months apart both confirm azoospermia. On examination his testes are small and firm with a reduced volume (6 mL bilaterally, normal ≥15 mL), and the vasa deferentia are palpable bilaterally. His results are:

What is the most appropriate management?