MRCOG Part 2 – Subfertility SBAs

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

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. 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 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 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 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 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 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 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 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 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 as she and her partner have being trying to conceive for two years without success. What percentage of couples will conceive after two years of unprotected regular sexual intercourse?

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?

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

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

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?

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 most common cause of this condition?

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. 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 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 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 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 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 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 regular with a cycle length of 42 days. On which day of her cycle should mid-luteal progesterone be measured?

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 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 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 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 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 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 on her booking bloods. Her BMI is 21 kg/m². Which of the following investigations should be offered?

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 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 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 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 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 32-year-old woman and her partner have a 2-year history of primary subfertility. She has regular ovulatory cycles confirmed by a mid-luteal progesterone, patent tubes on hysterosalpingography, and a normal pelvic ultrasound. Her partner’s semen analysis is normal on two occasions. Coeliac serology is negative. No cause has been identified, and they are have been given a diagnosis of unexplained subfertility. They have been having regular unprotected intercourse throughout and ask what treatment they should have now. What is the most appropriate management?

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 30-year-old woman is scheduled for IVF using a GnRH antagonist protocol with FSH-alone stimulation. For organisational reasons, the unit is considering pre-treating her with the combined oral contraceptive pill. Which statement is correct?

A 28-year-old woman with polycystic ovaries has an anti-Müllerian hormone level and antral follicle count indicating that she is a predicted high responder. According to the ESHRE guideline, which pituitary suppression protocol is recommended?

A 28-year-old woman with polycystic ovaries has an anti-Müllerian hormone level and antral follicle count indicating that she is a predicted high responder. Accordingly, the IVF unit plans for stimulation using a GnRH antagonist protocol. Which starting gonadotrophin dose is recommended in order to decrease her risk of ovarian hyperstimulation syndrome?

A 39-year-old having IVF treatment was a predicted low responder and had 3 oocytes retrieved in her previous cycle using 225 IU of gonadotrophin. The clinician proposes increasing her starting dose to 450 IU for the next cycle. Which statement is correct?

A 31-year-old woman with no adverse prognostic features is about to undergo her first IVF cycle. Which pituitary suppression protocol is recommended for the general IVF/ICSI population, and for what reason?

A 34-year-old woman has undergone an hCG-triggered ovarian stimulation cycle and a fresh embryo transfer is planned. Which agent is recommended for luteal phase support?

A 29-year-old woman with polycystic ovary syndrome is to undergo IVF using a GnRH antagonist protocol. Her clinician asks whether adjunct metformin should be given routinely before and during ovarian stimulation. What is the correct approach?

A 30-year-old woman is diagnosed with a haematological malignancy and requires urgent gonadotoxic chemotherapy. She wishes to undergo oocyte cryopreservation. She presents to the fertility unit on day 19 of her menstrual cycle., What is the most appropriate approach?

A 34-year-old woman with newly diagnosed oestrogen receptor-positive breast cancer is undergoing ovarian stimulation for fertility preservation before chemotherapy. She is concerned about the supraphysiological oestradiol levels generated by stimulation. Which statement is correct?

A 24-year-old oocyte donor with a high antral follicle count is undergoing ovarian stimulation using a GnRH antagonist protocol. She has 22 follicles of 16 mm or more. Which agent should be used to trigger final oocyte maturation?

A 32-year-old woman has completed ovarian stimulation and a fresh embryo transfer is intended. Which hormonal measurement on the day of final oocyte maturation is recommended?

A 27-year-old woman is undergoing IVF using a long GnRH agonist protocol. On the day that final oocyte maturation is due to be triggered, ultrasound demonstrates 24 follicles measuring 11 mm or more. Which of the following is the recommended primary preventative measure against OHSS?

A 30-year-old normal responder has completed ovarian stimulation in a GnRH antagonist cycle. She is not at increased risk of OHSS and a fresh embryo transfer is planned. Which agent should be used to trigger final oocyte maturation?

A 26-year-old woman with polycystic ovaries has been stimulated in a GnRH antagonist cycle and now has 25 follicles of 11 mm or more with a markedly raised oestradiol. She is judged to be at high risk of OHSS. What is the recommended strategy?