MRCOG Part 2 – Subfertility EMQs

For each scenario described below, choose the single most appropriate management option:

• 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.

For each scenario described below, choose the single most appropriate management option:

• 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.

For each scenario described below, choose the single most appropriate management option:

• A 32-year-old woman with normal ovarian reserve (AMH 20 pmol/L, antral follicle count 15) is referred for in vitro fertilisation (IVF) due to tubal factor infertility. She has no significant medical history.

For each scenario described below, choose the single most appropriate management option:

• A 35-year-old woman undergoing IVF has a low AMH of 4 pmol/L and an antral follicle count of 4. Her previous cycle resulted in poor response with only 2 eggs retrieved, of which one developed to blastocyst stage and was transferred but did not result in a pregnancy.  She has a further cycle of IVF with GnRH agonist long protocol and four eggs are retrieved.  Two develop to blastocyst stage and are top quality quality embryos.

For each scenario described below, choose the single most appropriate management option:

• A 28-year-old woman with polycystic ovary syndrome (PCOS) is undergoing IVF with a GnRH antagonist fixed protocol. Her AMH is 40 pmol/L, and ultrasound reveals 25 antral follicles per ovary. Serum oestradiol is rising rapidly.

For each scenario described below, choose the single most appropriate management option:

• A 41-year-old woman undergoing IVF has a low AMH of 4 pmol/L and an antral follicle count of 4. Her previous cycle using a GnRH antagonist protocol resulted in poor response with only 2 eggs retrieved, of which one developed to blastocyst stage and was transferred but did not result in a pregnancy.  She is considering a further cycle of own egg IVF but wishes to avoid a prolonged course of treatment as she plans to have donor gamete IVF if unsuccessful.

For each scenario described below, choose the single most appropriate management option:

• A 28-year-old woman with polycystic ovary syndrome (PCOS) is planned for her first cycle of IVF. Her AMH is 40 pmol/L, and baseline ultrasound reveals 25 antral follicles per ovary.

For each scenario described below, choose the single most appropriate management option:

• A 41-year-old woman undergoing IVF has a low AMH of 4 pmol/L and an antral follicle count of 4. Her previous cycle resulted in poor response with only 2 eggs retrieved, of which one developed to blastocyst stage and was transferred but did not result in a pregnancy.  She has a further cycle of IVF with GnRH agonist long protocol and four eggs are retrieved.  Two develop to blastocyst stage but are moderate quality embryos.

For each scenario described below, choose the single most appropriate management option:

• A 26-year-old professional athlete with low BMI and secondary amenorrhoea presents with infertility. FSH and LH are low, and oestradiol levels are suppressed.

For each scenario described below, choose the single most appropriate management option:

• 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.

For each scenario described below, choose the single most appropriate management option:

• 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.

For each scenario described below, choose the single most appropriate management option:

• 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.

For each scenario described below, choose the single most appropriate management option:

• 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.

For each scenario described below, choose the single most appropriate management option:

• 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.

For each scenario described below, choose the single most appropriate management option:

• A 34-year-old man presents with primary infertility. His semen analysis reveals azoospermia with normal testicular volume and serum FSH. Ultrasound suggests congenital absence of vas deferens.

For each scenario described below, choose the single most appropriate management option:

• 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.

For each scenario described below, choose the single most appropriate management option:

• 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:

  Test	His result	Reference / interpretation
  Semen volume	2.6 mL	≥1.4 mL (WHO 6th ed.) — normal
  Sperm concentration	0	≥16 million/mL
  Semen pH	7.6	≥7.2 — normal
  FSH	22 IU/L	~1.5–12.4 (raised)
  LH	11 IU/L	~1.7–8.6 (mildly raised)
  Testosterone	9 nmol/L	Low–normal
  Testicular volume (US)	6 mL each	≥15 mL (reduced)
  Karyotype	46,XY	Normal
  Y microdeletion	No AZFa or AZFb deletion (partial AZFc noted)	Determines retrieval prognosis

For each scenario described below, choose the single most appropriate management option:

• 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 semen analysis is as follows:

  Parameter	Value
  Semen Volume (ml)	4.5
  Total Sperm number (106 per ejaculate)	2
  Sperm Concentration (106 per ml)	2
  Total motility (PR+NP [%])	14
  Sperm morphology (normal forms [%])	5

  His hormone profile shows very low FSH and LH levels, low testosterone and normal prolactin levels.

For each scenario described below, choose the single 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.

For each scenario described below, choose the single most appropriate management option:

• A 35-year-old woman with a history of secondary amenorrhea for 10 months and elevated FSH (>30 IU/L) presents with infertility. Her Anti-Müllerian hormone (AMH) level is very low.

For each scenario described below, choose the single most appropriate management option:

• 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.

For each clinical scenario below, select the SINGLE most appropriate option from the list below. Each option may be used once, more than once, or not at all.

• A 33-year-old woman has bilateral tubal occlusion for which other treatments are not suitable. She meets the access criteria and has never had IVF treatment, whether NHS-funded or self-funded.

For each clinical scenario below, select the SINGLE most appropriate option from the list below. Each option may be used once, more than once, or not at all.

• A 40-year-old woman meets the access criteria for IVF and has not had IVF treatment before, either privately or on the NHS.

For each clinical scenario below, select the SINGLE most appropriate option from the list below. Each option may be used once, more than once, or not at all.

• A 36-year-old woman who met the access criteria has completed 3 full cycles of NHS-funded IVF without conceiving. She remains well and wishes to continue treatment.

For each clinical scenario below, select the SINGLE most appropriate option from the list below. Each option may be used once, more than once, or not at all.

• A couple attend the fertility clinic. The male partner has azoospermia; surgical sperm retrieval has been attempted and was unsuccessful. They wish to proceed using donor sperm. The female partner is 30 years old with no known cause of infertility.

For each clinical scenario below, select the SINGLE most appropriate management option from the list below. Each option may be used once, more than once, or not at all.

• A couple wish to conceive. The male partner is HIV positive. He is fully compliant with highly active antiretroviral therapy and has had a plasma viral load of less than 50 copies/ml for the past 18 months. There are no other infections present, and they will limit unprotected intercourse to the time of ovulation.

For each clinical scenario below, select the SINGLE most appropriate management option from the list below. Each option may be used once, more than once, or not at all.

• A couple wish to conceive. The male partner is HIV positive but has been intermittently non-adherent to his antiretroviral therapy and his most recent plasma viral load is 320 copies/ml.

For each clinical scenario below, select the SINGLE most appropriate management option from the list below. Each option may be used once, more than once, or not at all.

• A 31-year-old woman is scheduled for hysterosalpingography as part of her fertility investigations.

For each clinical scenario below, select the SINGLE most appropriate management option from the list below. Each option may be used once, more than once, or not at all.

• A 29-year-old woman concerned about her fertility is uncertain whether she was ever vaccinated against rubella. Testing shows that she is not immune.

For each clinical scenario below, select the SINGLE most appropriate option from the list below. Each option may be used once, more than once, or not at all.

• A 28-year-old woman with premature ovarian insufficiency, confirmed on repeated hormonal testing, wishes to conceive. Pelvic ultrasound is normal and her partner’s semen analysis is normal.

For each clinical scenario below, select the SINGLE most appropriate option from the list below. Each option may be used once, more than once, or not at all.

• A 16-year-old boy is due to begin gonadotoxic chemotherapy for Hodgkin lymphoma. He is post-pubertal and able to produce a semen sample.

For each clinical scenario below, select the SINGLE most appropriate option from the list below. Each option may be used once, more than once, or not at all.

• A 15-year-old girl requires pelvic radiotherapy. The local commissioner questions whether she can access NHS-funded fertility preservation, given that she is below the usual lower age limit for fertility treatment.

For each clinical scenario below, select the SINGLE most appropriate option from the list below. Each option may be used once, more than once, or not at all.

• A 24-year-old man had sperm cryopreserved before chemotherapy 5 years ago. He remains in remission. The fertility service asks what should now happen with regard to his stored sample.