Subfertility

Question 1

A 30 year old woman was diagnosed as polycystic ovarian syndrome and presents with primary subfertility of 4 years. Her BMI is 20. Her partner’s semen analysis is satisfactory. Hysterosalpingography has confirmed bilateral tubal patency. What is the most appropriate first line treatment for this couple?

a. IVF
b. ICSI
c. IUI
d. Ovulation induction with clomiphene citrate
e. Ovulation induction with gonadotrophins and IUI

Answer 1

D – Ovulation induction with clomiphene citrate

Question 2

A 26 year old man is referred to the fertility clinic with a history of secondary subfertility. Semen analysis demonstrated azoospermia on two separate occasions, 2 months apart. His hormone profile has demonstrated drastically reduced FSH and LH concentrations. What is the most likely explanation for this?

a. Cystic fibrosis carrier
b. Kleinfelter syndrome
c. Anabolic steroid use
d. Azathioprine use
e. Varicocoele

Answer 2

C - Anabolic steroid use

Low FSH and LH suggest hypogonadotropic hypogonadism. None of the other conditions listed fit with the history of prior childbearing. Azathioprine has no effect on spermatogenesis.

Question 3

A woman who suffers from health anxiety is planning to start a family with her partner. Both are in their mid-twenties and in good physical health. She asks how long it is likely to take her to fall pregnant. What proportion of couples, where both partners are under 40, not on contraception and having regular intercourse, can expect to conceive within 12 months of starting trying?

a. 50%
b. 60%
c. 70%
d. 80%
e. 90%

Answer 3

D - 80%

80% of healthy couples, not on contraception and having regular intercourse can expect to conceive within the first 12 months of trying. This is increased to 90% in the first 24 months.

Question 4

A couple in their early-thirties are seen in primary care. They have been trying to conceive for 12 months without success and are anxious there may be a fertility problem. Both are in good physical health, not on contraception and having regular intercourse. What proportion of couples with such a history could be expected to conceive within the subsequent 12 months?

a. 25%
b. 40%
c. 50%
d. 75%
e. 90%

Answer 4

C - 50%

80% of healthy couples, not on contraception and having regular intercourse can expect to conceive within the first 12 months of trying. This is increased to 90% in the first 24 months - i.e. 50% of couples of who have not conceived by 12 months can expect to do so within the next year.

Question 5

A woman in a same-sex relationship attends the gynaecology clinic for advice. She and her partner have been trying to conceive using donor sperm and artificial insemination for over a year now. In total they have tried 6 cycles. What proportion of couples using artificial insemination can expect to conceive within 6 cycles of artificial insemination

a. 40%
b. 50%
c. 60%
d. 75%
e. 85%

Answer 5

B - 50%

Couples using artificial insemination may be advised that 50% will conceive within 6 cycles and 75% within 12

Question 6

A woman in a same-sex relationship attends the gynaecology clinic for advice. She and her partner have been trying to conceive using donor sperm and artificial insemination for over a year now. In total they have tried 12 cycles. What proportion of couples using artificial insemination can expect to conceive within 12 cycles of artificial insemination?

a. 40%
b. 50%
c. 60%
d. 75%
e. 90%

Answer 6

D - 75%

Couples using artificial insemination may be advised that 50% will conceive within 6 cycles and 75% within 12

Question 7

A couple who have been trying to conceive for 6 months without success are seen in the gynaecology clinic. Neither have children already. Both are in their mid-twenties and in good physical health. After what time interval of trying to conceive without success (since starting) should they be offered further investigation?

a. 6 months
b. 12 months
c. 24 months
d. 36 months
e. 48 months

Answer 7

B - 12 months

Question 8

A woman who is currently planning a pregnancy with her husband sees her GP for pre-conceptual advice. In particular she asks about lifestyle factors which may hamper their chances of success. What is the maximum level of alcohol which women trying to conceive should be advised to consume on a weekly basis?

a. No alcohol recommended while trying to conceive
b. 1-2 units/week
c. 3-4 units/week
d. 8-9 units/week
e. 13-14 units/week

Answer 8

B - 1-2 units/week

Women trying to conceive should be advised to consume no more than 1-2 units of alcohol per week. For men, up to 3-4 units/day are unlikely to affect semen quality.

Question 9

A couple are undergoing fertility investigations. The male partner has had semen analysis performed and oligozoospermia is diagnosed. What is a normal sperm concentration according to the WHO reference ranges?

a. 1.5 million/ml
b. 5 million/ml
c. 15 million/ml
d. 50 million/ml
e. 150 million/ml

Answer 9

C - 15 million/ml

Normal parameters for semen analysis are as follows:

Volume 1.5ml or more
pH 7.2 or more
Concentration 15 million/ml
Total number >39 million per ejaculate
Total motility 40% or more motile/32% or more with progressive motility
Vitality 58% or more alive
Normal forms 4% or more

Question 10

A couple are undergoing fertility investigations. The male partner has had semen analysis performed and asthenozoospermia is diagnosed. According to the WHO reference ranges, what is considered normal sperm motility?

a. 15% or more motile
b. 30% or more motile
c. 40% or more motile
d. 60% or more motile
e. 80% or more motile

Answer 10

C - 40% or more motile

Volume 1.5ml or more
pH 7.2 or more
Concentration 15 million/ml
Total number >39 million per ejaculate
Total motility 40% or more motile/32% or more with progressive motility
Vitality 58% or more alive
Normal forms 4% or more

Question 11

A couple are undergoing fertility investigations. The male partner has had semen analysis performed and teratozoospermia is diagnosed. What is a normal proportion of ‘normal forms’ in a semen sample according to the WHO reference ranges?

a. 4% or more
b. 7% or more
c. 15% or more
d. 30% or more
e. 45% or more

Answer 11

A - 4% or more

Volume 1.5ml or more
pH 7.2 or more
Concentration 15 million/ml
Total number >39 million per ejaculate
Total motility 40% or more motile/32% or more with progressive motility
Vitality 58% or more alive
Normal forms 4% or more

Question 12

What is the normal lower limit seminal fluid pH according to the WHO reference ranges?

a. 6.9
b. 7.0
c. 7.1
d. 7.2
e. 7.3

Answer 12

D - 7.2

Volume 1.5ml or more
pH 7.2 or more
Concentration 15 million/ml
Total number >39 million per ejaculate
Total motility 40% or more motile/32% or more with progressive motility
Vitality 58% or more alive
Normal forms 4% or more

Question 13

The male partner in a couple undergoing fertility investigations has a semen analysis performed which is reported as showing oligozoospermia, with a sperm concentration of 9 million/ml. When, if at all, should this sample be repeated?

a. Immediately
b. 1 month
c. 2 months
d. 3 months
e. No need to repeat

Answer 13

D - 3 months

Question 14

A couple are referred for IVF after undergoing extensive fertility investigations which all return normal results. Which of the following should be considered the primary indicator of success in couples planning IVF?

a. Antral follicle count
b. Length of infertility
c. AMH levels
d. FSH levels
e. Age of female partner

Answer 14

E - Age of female partner

Question 15

A woman undergoes a pelvic ultrasound scan prior to gonadotrophin stimulation as part of an IVF cycle. Above what value of antral follicle count is considered predictive of a high response?

a. 4
b. 8
c. 12
d. 16
e. 20

Answer 15

D - 16

Antral follicle count, AMH and FSH levels all may be used as predictors of success of gonadotrophin stimulation in IVF. The following reference ranges are used:

• Antral follicle count:
o <4 for a low response
o >16 for a high response

• AMH:
o <5.4 for low response
o >25 for a high response

• FSH:
o >8.9 for low response
o <4 for high response

Question 16

A woman has her anti-Müllerian hormone levels checked prior to gonadotrophin stimulation as part of an IVF cycle. Above what value of anti-Müllerian hormone is considered predictive of a high response?

a. 5
b. 10
c. 25
d. 50
e. 75

Answer 16

C - 25

Antral follicle count, AMH and FSH levels all may be used as predictors of success of gonadotrophin stimulation in IVF. The following reference ranges are used:

• Antral follicle count:
o <4 for a low response
o >16 for a high response

• AMH:
o <5.4 for low response
o >25 for a high response

• FSH:
o >8.9 for low response
o <4 for high response

Question 17

A woman has her follicle stimulating hormone levels checked prior to gonadotrophin stimulation as part of an IVF cycle. What value of FSH is considered predictive of a high response?

a. <4
b. <8
c. <10
d. >12
e. >14

Answer 17

A - <4

Antral follicle count, AMH and FSH levels all may be used as predictors of success of gonadotrophin stimulation in IVF. The following reference ranges are used:

• Antral follicle count:
o <4 for a low response
o >16 for a high response

• AMH:
o <5.4 for low response
o >25 for a high response

• FSH:
o >8.9 for low response
o <4 for high response

Question 18

What test may be used to confirm ovulation in women with a regular menstrual cycle?

a. Follicular phase progesterone
b. Luteal phase progesterone
c. FSH/LH levels
d. Oestradiol
e. Anti-Müellerian hormone

Answer 18

B - Luteal phase progesterone

In women with a regular cycle, progesterone measured in the luteal phase may be used to assess the likelihood that the woman is ovulating. Women with irregular cycles may need to rely on FSH/LH levels.

Question 19

What test may be used to confirm ovulation in women with an irregular menstrual cycle?

a. Follicular phase progesterone
b. Luteal phase progesterone
c. FSH/LH levels
d. Oestradiol
e. Anti-Müellerian hormone

Answer 19

C - FSH/LH levels

In women with a regular cycle, progesterone measured in the luteal phase may be used to assess the likelihood that the woman is ovulating. Women with irregular cycles may need to rely on FSH/LH levels.

Question 20

A couple are referred to the fertility clinic for investigation following several years of trying for a pregnancy without success. Both partners are fit and well with no specific past-medical history of note. There is no history of pelvic infection. Which of the following tests should be undertaken first line to investigate tubal patency?

a. Non-contrast ultrasound
b. Hysterosalpingogram
c. Hysteroscopy
d. Laparoscopy and dye test
e. MRI pelvis

Answer 20

B - Hysterosalpingogram

The NICE fertility guideline suggests that hysterosalpingogram (HSG) is the preferred first line investigation of tubal patency in women who’s history does not suggest co-morbidities (PID, previous ectopic or endometriosis) as it is a ‘more reliable, less invasive and more efficient’ test than laparoscopy. HyCoSy is ‘an acceptable alternative’ in experienced hands.

Women who are thought likely to have co-morbidities predisposing to tubal pathology should proceed directly to laparoscopy and dye testing.

Question 21

A couple are referred to the fertility clinic for investigation following several years of trying for a pregnancy without success. On questioning, the female partner discloses a history of chlamydial infection and pelvic inflammatory disease some 3 years earlier. Which of the following tests should be undertaken first line to investigate tubal patency?

a. Non-contrast ultrasound
b. Hysterosalpingogram
c. Hysteroscopy
d. Laparoscopy and dye test
e. HyCoSy

Answer 21

D - Laparoscopy and dye test

The NICE fertility guideline suggests that hysterosalpingogram (HSG) is the preferred first line investigation of tubal patency in women who’s history does not suggest co-morbidities (PID, previous ectopic or endometriosis) as it is a ‘more reliable, less invasive and more efficient’ test than laparoscopy. HyCoSy is ‘an acceptable alternative’ in experienced hands.

Women who are thought likely to have co-morbidities predisposing to tubal pathology should proceed directly to laparoscopy and dye testing.

Question 22

A woman undergoing fertility investigations is found to be susceptible to Rubella infection and is offered vaccination. How long after Rubella vaccination should she be advised to avoid pregnancy?

a. 1 week
b. 4 weeks
c. 6 weeks
d. 3 months
e. 6 months

Answer 22

B - 4 weeks

Women should be advised to avoid pregnancy for 4 weeks following rubella/MMR vaccination

Question 23

A couple undergoing fertility investigations are found to be affected by male hypogonadotrophic hypogonadism. What is the first line treatment for this condition in improving fertility rates?

a. Testosterone
b. ICSI
c. Intra-uterine insemination
d. Gonadotrophin injections
e. No treatment of proven benefit

Answer 23

D - Gonadotrophin injections

Much like in females, male hypogonadotrophic hypogonadism may be treated with gonadotrophins

Question 24

A woman with polycystic ovarian syndrome is found to have anovulatory cycles and is commenced on clomiphene citrate therapy. For how long should this be continued?

a. 3 cycles
b. 6 cycles
c. 9 cycles
d. 12 cycles
e. 18 cycles

Answer 24

B - 6 cycles

Ultrasound monitoring during the first cycle to ensure the dose given minimises the risk of multiple pregnancy is advised

Question 25

A patient with confirmed anovulatory cycles secondary to polycystic ovarian syndrome has an complete course of clomiphene though mid-luteal progesterone levels suggest a sub-optimal response and she does not fall pregnant. Which of the following is an appropriate next step?

a. 3 cycles of clomiphene with intra-uterine insemination
b. IVF
c. High dose GnRH analogues and FSH/LH together
d. Luteal phase high-dose progesterone
e. Laparoscopic ovarian drilling

Answer 25

E - Laparoscopic ovarian drilling

For women with Group 2 ovulatory disorders (WHO classification) - that is to say hypothalamic-pituitary dysfunction (principally PCOS), clomiphene citrate ovulation induction for 6 cycles is first line.

In women known to be resistant to clomiphene, the following should be considered second line:

• Laparoscopic ovarian drilling
• Clomiphene and metformin together
• Gonadotrophins (though NOT with concurrent GnRH)

Question 26

A patient is reviewed in the subfertility clinic following investigations, the results of which are as follows:
•	Day 21 progesterone - 19
•	Day 3 FSH/LH – normal
•	Tubal patency testing – normal
•	Thyroid function testing – normal
•	Serum prolactin – 1125
•	Semen analysis – normal
What first line treatment is appropriate here?

a. Clomiphene citrate
b. FSH/LH
c. Bromocriptine
d. IVF with ICSI
e. Domperidone

Answer 26

C - Bromocriptine

Question 27

A patient with known bilateral hydrosalpinges is reviewed in the fertility clinic with the results of investigations. Her hormone profile and her partner’s semen analysis are both reported as normal and tubal obstruction is felt to be the most likely cause for her inability to conceive. What next step in management is most appropriate here?

a. IVF
b. IVF with ICSI
c. Intrauterine insemination
d. Laparoscopic bilateral salpingectomy
e. Laparoscopic bilateral drainage of hydrosalpinges

Answer 27

D - Laparoscopic bilateral salpingectomy

Question 28

After 2 years of trying and extensive investigation, a couple are diagnosed with ‘unexplained’ infertility. They are both in good general, physical health. What management is appropriate?

a. Induction of ovulation with gonadotrophins
b. Induction of ovulation with clomiphene citrate
c. Intra-uterine insemination
d. IVF
e. IVF with ICSI

Answer 28

D - IVF

Question 29

A patient undergoing IVF is scheduled for embryo transfer. She undergoes a trans-vaginal ultrasound on the morning of the planned procedure to assess endometrial thickness. What is the minimum endometrial thickness that should be achieved prior to embryo transfer?

a. 2mm
b. 3mm
c. 5mm
d. 7mm
e. 10mm

Answer 29

C - 5mm

Question 30

A 35 year old woman is undergoing her first cycle of IVF following a diagnosis of unexplained infertility. She wishes to know how many embryos will be transferred. What do you advise?

a. Single embryo transfer
b. Single embryo transfer if top-quality embryo; 2 if no top quality embryos
c. Double embryo transfer
d. Double embryo transfer if at least one top-quality embryo available, 3 if no top quality embryos
e. Triple embryo transfer

Answer 30

A - Single embryo transfer

Guidance on embryo transfer depends on age and number of previous IVF cycles as follows:

• Women <37:
o 1st cycle – single embryo transfer
o 2nd cycle – single if top-quality; 2 embryos if no top-quality available
o 3rd cycle – no more than 2

• Women 37-39
o 1st and 2nd – single if top quality, 2 embryos if no top quality
o 3rd – no more than 2

• Women 40-42
o 2 embryo transfer

Question 31

A 33 year old woman is undergoing her second cycle of IVF following a diagnosis of unexplained infertility. She wishes to know how many embryos will be transferred. What do you advise?

a. Single embryo transfer
b. Single embryo transfer if top-quality embryo; 2 if no top quality embryos
c. Double embryo transfer
d. Double embryo transfer if at least one top-quality embryo available, 3 if no top quality embryos
e. Triple embryo transfer

Answer 31

B - Single embryo transfer if top quality embryo; 2 if no top quality embryos

Guidance on embryo transfer depends on age and number of previous IVF cycles as follows:

• Women <37:
o 1st cycle – single embryo transfer
o 2nd cycle – single if top-quality; 2 embryos if no top-quality available
o 3rd cycle – no more than 2

• Women 37-39
o 1st and 2nd – single if top quality, 2 embryos if no top quality
o 3rd – no more than 2

• Women 40-42
o 2 embryo transfer

Question 32

A 28 year old woman is undergoing her third cycle of IVF following a diagnosis of unexplained infertility. She wishes to know how many embryos will be transferred. What do you advise?

a. Single embryo transfer
b. Single embryo transfer if top-quality embryo; 2 if no top quality embryos
c. Double embryo transfer
d. Double embryo transfer if at least one top-quality embryo available, 3 if no top quality embryos
e. Triple embryo transfer

Answer 32

C - Double embryo transfer

Guidance on embryo transfer depends on age and number of previous IVF cycles as follows:

• Women <37:
o 1st cycle – single embryo transfer
o 2nd cycle – single if top-quality; 2 embryos if no top-quality available
o 3rd cycle – no more than 2

• Women 37-39
o 1st and 2nd – single if top quality, 2 embryos if no top quality
o 3rd – no more than 2

• Women 40-42
o 2 embryo transfer

Question 33

A 37 year old woman is undergoing her first cycle of IVF following a diagnosis of unexplained infertility. She wishes to know how many embryos will be transferred. What do you advise?

a. Single embryo transfer
b. Single embryo transfer if top-quality embryo; 2 if no top quality embryos
c. Double embryo transfer
d. Double embryo transfer if at least one top-quality embryo available, 3 if no top quality embryos
e. Triple embryo transfer

Answer 33

B - Single embryo transfer if top-quality embryo; 2 if no top quality embryos

Guidance on embryo transfer depends on age and number of previous IVF cycles as follows:

• Women <37:
o 1st cycle – single embryo transfer
o 2nd cycle – single if top-quality; 2 embryos if no top-quality available
o 3rd cycle – no more than 2

• Women 37-39
o 1st and 2nd – single if top quality, 2 embryos if no top quality
o 3rd – no more than 2

• Women 40-42
o 2 embryo transfer

Question 34

A 39 year old woman is undergoing her second cycle of IVF following a diagnosis of unexplained infertility. She wishes to know how many embryos will be transferred. What do you advise?

a. Single embryo transfer
b. Single embryo transfer if top-quality embryo; 2 if no top quality embryos
c. Double embryo transfer
d. Double embryo transfer if at least one top-quality embryo available, 3 if no top quality embryos
e. Triple embryo transfer

Answer 34

C - Double embryo transfer

Guidance on embryo transfer depends on age and number of previous IVF cycles as follows:

• Women <37:
o 1st cycle – single embryo transfer
o 2nd cycle – single if top-quality; 2 embryos if no top-quality available
o 3rd cycle – no more than 2

• Women 37-39
o 1st and 2nd – single if top quality, 2 embryos if no top quality
o 3rd – no more than 2

• Women 40-42
o 2 embryo transfer

Question 35

A 40 year old woman is undergoing her first cycle of IVF following a diagnosis of unexplained infertility. She wishes to know how many embryos will be transferred. What do you advise?

a. Single embryo transfer
b. Single embryo transfer if top-quality embryo; 2 if no top quality embryos
c. Double embryo transfer
d. Double embryo transfer if at least one top-quality embryo available, 3 if no top quality embryos
e. Triple embryo transfer

Answer 35

C - Double embryo transfer

Guidance on embryo transfer depends on age and number of previous IVF cycles as follows:

• Women <37:
o 1st cycle – single embryo transfer
o 2nd cycle – single if top-quality; 2 embryos if no top-quality available
o 3rd cycle – no more than 2

• Women 37-39
o 1st and 2nd – single if top quality, 2 embryos if no top quality
o 3rd – no more than 2

• Women 40-42
o 2 embryo transfer

Question 36

A patient undergoes a single embryo transfer IVF cycle. She is extremely anxious and asks if any supplementary therapy will be offered to improve the outcome and chance of a successful pregnancy. What therapy may be offered for luteal phase support to IVF pregnancies for the first 8 weeks following re-implantation?

a. Oestradiol
b. Progesterone
c. Beta-hCG
d. Recombinant urinary gonadotrophins
e. No treatment of proven benefit

Answer 36

B - Progesterone

Progesterone for the first 8 weeks to provide luteal support is advised. There is no evidence to support ongoing progesterone therapy beyond this.

Question 37

A 19 year old woman is preparing to undergo cytotoxic chemotherapy following a diagnosis of Hodgkin’s lymphoma and wishes to discuss oocyte cryopreservation. How long should you advise her any eggs will be stored?

a. 5 years
b. 10 years
c. 15 years
d. 25 years
e. No time limit

Answer 37

B - 10 years

Curiously the guideline mentions that for men, storing sperm beyond 10 years should be considered for men ‘who remain at risk of significant infertility’.

Question 38

Risk of what malignancy is known to be increased amongst women undergoing assisted reproductive techniques?

a. Breast
b. Cervical
c. Endometrial
d. Haematological
e. None of the above

Answer 38

E - None of the above

There is no firm evidence of a link between assisted reproductive techniques and malignancy.

An association between IVF and a small increased risk of borderline ovarian tumours ‘cannot be ruled out’

Question 39

What regimen of exercise is advised for obese women experiencing fertility problems in whom weight loss is indicated?

a. Mild intensity for 120 minutes 7 days a week
b. Moderate intensity for 90 minutes 5 days a week
c. Moderate intensity for 45 minutes 5 days a week
d. High intensity for 30 minutes 3 days a week
e. High intensity for 60 minutes 5 days a week

Answer 39

B - Moderate intensity for 90 minutes 5 days a week

TOG 2017

Question 40

What is the mortality rate associated with bariatric surgery?

a. 1%
b. 2-3%
c. 4-5%
d. 7-8%
e. 10%

Answer 40

A - 1%

TOG 2017

Question 41

How long following bariatric surgery should patients be advised to defer pregnancy?

a. 6 months
b. 12 months
c. 3 years
d. 4 years
e. 5 years

Answer 41

B - 12 months

TOG 2017

Question 42

According to NICE guidelines on fertility, what BMI should be attained by patients wishing to undergo assisted reproduction?

a. <40
b. <35
c. <30
d. <28
e. <26

Answer 42

C - <30

TOG 2017

Question 43

What is the main difference between an obese and a non-obese woman undergoing IVF/ICSI with respect to live birth rates after their first ART cycle?

a. Women with a BMI of > 30 kg/M2 have up to 20% lower risk of having a live birth compared to those with BMI< 30 kg/M2
b. Women with a BMI of > 30kg/M2 have up to 30% lower risk of having a live birth compared to those with BMI< 30kg/M2
c. Women with a BMI of > 30kg/M2 have up to 50% lower risk of having a live birth compared to those with BMI< 30kg/M2
d. Women with a BMI of > 30kg/M2 have up to 60% lower risk of having a live birth compared to those with BMI< 30kg/M2
e. Women with a BMI of > 30kg/M2 have up to 70% lower risk of having a live birth compared to those with BMI< 30kg/M2

Answer 43

E - Women with a BMI of > 30kg/M2 have up to 70% lower risk of having a live birth compared to those with BMI< 30kg/M2

TOG 2017

Question 44

What would be the recommended duration of physical activity for a 30 year old obese (body mass index of 33 kg/M2) woman who is trying to conceive?

a. Moderate intensity for at least 30−40 minutes on three or more occasions each week
b. Moderate intensity for at least 30−40 minutes on four or more occasions each week
c. Moderate intensity for at least 30−40 minutes on five or more occasions each week
d. Moderate intensity for at least 60−90 minutes daily four or more occasions each week
e. Moderate intensity for at least 60−90 minutes on five or more occasions each week

Answer 44

E - Moderate intensity for at least 60−90 minutes on five or more occasions each week

TOG 2017

Question 45

In which of the following population groups has pre-treatment with GnRH agonists for 3-6 months prior to assisted reproduction been shown to increase clinical pregnancy rates 4-fold?

a. Endometriosis
b. Hypogonadotrophic hypogonadism
c. Recurrent miscarriage
d. Premature ovarian failure
e. Idiopathic subfertility

Answer 45

A - Endometriosis

Question 46

How many antral follicles develop during a normal menstrual cycle?

a. 1-2
b. 4-5
c. 5-10
d. 10-20
e. 25-30

Answer 46

D - 10-20

Question 47

What is the preferred agent for mimicking the mid-cycle LH surge in ART to achieve final follicular maturation and luteinisation?

a. Recombinant LH
b. Urinary LH
c. GnRH
d. Recombinant hCG
e. Urinary hCG

Answer 47

E - Urinary hCG

Question 48

At what cell stage does embryo transfer typically take place in IVF cycles?

a. 4 cell
b. 16 cell
c. 32 cell
d. 64 cell
e. 128 cell

Answer 48

D - 64 cell

Question 49

A 35 year old woman undergoes her first cycle of IVF for unexplained infertility. How many embryos should be transferred?

a. 1
b. 2
c. 3
d. 4
e. 5

Answer 49

A - 1

Question 50

What is national target for multiple birth associated with ART set by the Human Fertility and Embryological Authority (HFEA)?

a. <5%
b. 10%
c. 15%
d. 20%
e. 25%

Answer 50

B - 10%

Question 51

A couple undergo embryo transfer as part of an IVF cycle. They wish to know when they should perform a pregnancy test to assess if successful implantation has occurred. How long from oocyte retrieval should a urine pregnancy test be performed?

a. 24 hours
b. 28 hours
c. 7 days
d. 14 days
e. 28 days

Answer 51

D - 14 days

Question 52

How many days after the hCG trigger in oocyte retrieval as a component of assisted reproduction does ‘late’ (as opposed to early) ovarian hyperstimulation syndrome occur?

a. 5
b. 7
c. 10
d. 14
e. 21

Answer 52

C - 10 days

Question 53

How much greater is the risk of multiple pregnancy with assisted reproduction compared with spontaneous conception?

a. 2x
b. 4x
c. 10x
d. 20x
e. 50x

Answer 53

D - 20x

Question 54

What is the incidence of hetero-ectopic pregnancy in assisted reproduction?

a. 1 in 30,000
b. 1 in 10,000
c. 1 in 1000
d. 3 in 1000
e. 8 in 1000

Answer 54

E - 8 in 1000

Question 55

Which of the following cancers has been shown to be increased amongst women undergoing assisted reproductive techniques?

a. Breast
b. Endometrial
c. Ovarian
d. Cervical
e. None of the above

Answer 55

E - None of the above

Question 56

What is the strongest predictor of success of assisted reproductive techniques?

a. Previous obstetric history
b. Medical history
c. Number of previous failed cycles
d. Maternal age
e. Body mass index

Answer 56

D - Maternal age

Question 57

A 35 year old woman with subfertility is undergoing abdominal myomectomy. What are the chances of her achieving a successful, spontaneous pregnancy assuming there are no other factors present which may affect her fertility?

a. 25%
b. 33%
c. 50%
d. 67%
e. 75%

Answer 57

D - 67%

Question 58

A 30 year old woman with endometriosis and her partner present with difficulties conceiving after 3 years of trying. Following investigations, ART is offered as the best option. What effect – if any – may pre-treatment with a GnRH analogue for 3-6 months have on pregnancy rates in this couple?

a. Decrease the pregnancy rate
b. Decrease the quality of oocytes obtained following controlled ovarian stimulation and therefore increase implantation failure
c. Increase the clinical pregnancy rate more than four-fold
d. Increase the treatment to conception interval
e. No difference

Answer 58

C - Increase the clinical pregnancy rate more than four-fold

Question 59

What is the best step to take in reducing the risk of ovarian hyperstimulation syndrome in a woman undergoing a GnRH antagonist controlled ovarian stimulation for in vitro fertilisation with an intact HPO axis?

a. Administer GnRH agonist for the maturation trigger
b. Administer recombinant hCG
c. Cancel the cycle
d. Delay administration of hCG
e. Withhold administration of hCG

Answer 59

A - Administer GnRH agonist for the maturation trigger

Question 60

What is the prevalence of ectopic pregnancy amongst women undergoing assisted reproductive treatment?

a. 1-2%
b. 2-10%
c. 5-15%
d. 10-15%
e. 15-20%

Answer 60

B - 2-10%

Question 61

What is the effect of controlled ovarian stimulation on follicular reserve in a 36 year old woman undergoing assisted reproductive technology?

a. Depletes ovarian reserve leading to early menopause
b. Depletes antral-follicle pool making subsequent controlled ovarian stimulation less likely to be successful
c. Depletes the pool of best quality follicles
d. Down regulation allows preservation of more follicle therefore delaying the onset of menopause
e. Does not have any effect on ovarian reserve

Answer 61

E - Does not have any effect on ovarian reserve

Question 62

Precocious puberty is defined as the onset of puberty in females before what age?

a. 6 years
b. 7 years
c. 8 years
d. 9 years
e. 10 years

Answer 62

C - 8 years

Precocious puberty is the development of secondary sexual characteristics/menses in females under 8 years old (9 years in boys).

TOG 2016

Question 63

There is a known dose dependent association between pelvic radiotherapy and ovarian function. What doses of radiation are considered to cause effective sterilisation in women exposed to pelvic radiation in the first 20 years of life?

a. 1-2Gy
b. 5-10Gy
c. 15-20Gy
d. 100-150Gy
e. 1000-2000Gy

Answer 63

C - 15-20Gy

The dose of pelvic radiation required to achieve effective sterilisation falls with age from ~20Gy at birth to 16.5Gy at 20 years

TOG 2016

Question 64

A mother seeks advice regarding future fertility after her 8 year old daughter is diagnosed with acute lymphoblastic leukaemia. What is the rate of acute ovarian failure amongst female survivors of childhood cancer?

a. 1-2%
b. 5-10%
c. 15-20%
d. 45-50%
e. 60-70%

Answer 64

B - 5-10%

Rates of acute ovarian failure (occurring during or within 5 years of cancer treatment) in survivors of cancer is quoted at 6.5% by the CCSS

TOG 2016

Question 65

What is the most significant risk factor for acute ovarian failure in female survivors of childhood malignancy?

a. Anthracycline chemotherapy
b. Non-haematological malignancy
c. Ionising radiation in diagnosis and staging
d. Diagnosis of cancer <5 years of age
e. Pelvic radiotherapy

Answer 65

E - Pelvic radiotherapy

TOG 2016

Question 66

What is the rate of premature menopause (onset of menopause <40 year of age) amongst female survivors of childhood cancer?

a. <5%
b. 5-10%
c. 20-25%
d. 45-50%
e. 65-70%

Answer 66

B - 5-10%

The rate of premature menopause is quoted at ~8% by the CCSS

TOG 2016

Question 67

A girl of 7 years has been diagnosed with leukaemia and is offered chemotherapy. Which anticancer agent has been most definitely associated with gonadotoxicity in girls?

a. Alkylating agents
b. Antibiotics
c. Antimetabolites
d. Nitrosuria
e. Vinca alkaloids

Answer 67

A - Alkylating agents

Chemotherapy may damage the ovaries through depletion of follicles, thus ovarian function and reserve and may result in premature ovarian failure. The effects of chemotherapy on the ovary are related to cumulative dose, the specific agent used, length of treatment and older age at treatment. Alkylating agents are the main chemotherapeutic are associated with gonadotoxicity. Most girls, however, retain or recover ovarian function if they are treated with low-risk chemothera

TOG StratOG Resource 2016

Question 68

Human leucocyte antigens (HLA) enable the immune system to differentiate between native and foreign proteins. HLA-A, -B and –C are known collectively as ‘classical HLA’ and are expressed on all nucleated cell types bar one. Which of the following cells does NOT express classical HLA?

a. Endometrial columnar cells
b. Extravillous cytotrophoblasts
c. Intermediate mesodermal progenitor cells
d. Natural killer cells
e. Primary oocytes

Answer 68

B - Extravillous trophoblast

HLA A, B and C are expressed on all nucleated cells with the singular exception of extravillous trophoblast

TOG 2016

Question 69

Which of the following cell surface antigens is found in greatest abundance on uterine natural killer cells?

a. CD4
b. CD8
c. CD16
d. CD32
e. CD56

Answer 69

E - CD56

This is in comparison to peripheral natural killer cells (pNK) which exhibit CD16 but are low in CD56.

The expression may be represented as CD56(bright)/CD16(-)

TOG 2016

Question 70

A couple who are both known to be carriers of an autosomal recessive disorder are considering pre-implantation genetic diagnosis. What is the most common autosomal recessive disorder amongst Caucasians in Europe?

a. Sickle cell disease
b. Tay-sachs disease
c. Marfan’s syndrome
d. Cystic fibrosis
e. Beta-thalassaemia

Answer 70

D - Cystic fibrosis

European caucasians - CF

Worldwide - Beta-Thalassamiea

TOG 2016

Question 71

A couple who are both known to be carriers of an autosomal recessive disorder are considering pre-implantation genetic diagnosis. What is the most common autosomal recessive disorder worldwide?

a. Sickle cell disease
b. Huntington’s chorea
c. BRCA 1
d. Cystic fibrosis
e. Beta-thalassaemia

Answer 71

E - Beta-thalassaemia

TOG 2016

Question 72

A couple are considering pre-implantation genetic diagnosis to implant an embryo which is HLA-matched with their existing child who suffers from leukaemia in the hope that stem cells from the cord blood might provide a cure. On what chromosome is the locus coding for HLA molecules found?

a. Chromosome 1
b. Chromosome 6
c. Chromosome 14
d. Chromosome 19
e. X Chromosome

Answer 72

B - Chromosome 6

TOG 2016

Question 73

A couple are considering pre-implantation genetic diagnosis to implant an embryo which is HLA-matched with their existing child who suffers from beta-thallasaemia in the hope that stem cells from the cord blood might provide a cure. Under such circumstances, what is the chance of them obtaining an embryo which is viable, free itself from the condition and HLA-compatible?

a. 1 in 20
b. 1 in 15
c. 1 in 10
d. 3 in 16
e. 5 in 19

Answer 73

D - 3 in 16

TOG 2016

Question 74

At what cell stage are biopsies most commonly taken for pre-implantation genetic diagnosis?

a. Fertilised ovum
b. Day 2 cleavage
c. Day 3 cleavage
d. Morula
e. Blastocyst

Answer 74

E - Blastocyst

TOG 2016

Question 75

What proportion of infertility is – after investigation – unexplained?

a. 5-10%
b. 15-20%
c. 30-40%
d. 60-70%
e. 85-90%

Answer 75

C - 30-40%

TOG 2016

Question 76

What is the likelihood of conception, per cycle, amongst couples with unexplained subfertility?

a. <1%
b. Up to 2%
c. Up to 4%
d. Up to 9%
e. Up to 15%

Answer 76

B - Up to 4%

TOG 2016

Question 77

What is the single most important factor in determining reproductive outcome in couples who wish to conceive?

a. BMI
b. Smoking status
c. Previous pregnancies
d. Maternal age
e. Alcohol consumption

Answer 77

D - Maternal age

TOG 2016

Question 78

A 25 year old woman who is normally fit and well with no medical complaints or symptoms undergoes a laparoscopy and dye test during investigation into subfertility. What is the likelihood that endometriosis will be detected during this procedure?

a. 2%
b. 5%
c. 12%
d. 30%
e. 50%

Answer 78

D - 30%

Endometriosis will be found at laparoscopy in 30% of asymptomatic women during investigation for subfertility

TOG 2016

Question 79

A patient undergoes semen analysis during work up for subfertility – this is reported as showing severe azoospermia. What is the normal sperm concentration (x10^6) according to WHO parameters?

a. >1.5 million/ml
b. >5 million/ml
c. >15 million/ml
d. >50 million/ml
e. >150 million/ml

Answer 79

C - >15 million/ml

TOG 2016

Question 80

A patient undergoing fertility investigations is to have ovarian reserve testing by means of serum anti-muellerian hormone levels. At what stage in the menstrual cycle should this be measured?

a. Early follicular phase (days 2-5)
b. Late follicular phase (days 8-13)
c. Around predicted time of ovulation (day 19)
d. Late luteal phase (Day 25-28)
e. Any of the above

Answer 80

E - Any of the above

Unlike FSH which is timing specific, AMH may be measured at any stage in the menstrual cycle

TOG 2016

Question 81

After what period of unexplained subfertility do NICE recommend couples should be offered IVF?

a. 1 year
b. 2 years
c. 2.5 years
d. 3 years
e. 5 years

Answer 81

B - 2 years

TOG 2016

Question 82

A couple had three IVFs, all of which failed to achieve a pregnancy. On each occasion the woman had a positive pregnancy test but by the time she attended for an ultrasound scan no intrauterine sac was demonstrated. She was therefore labelled as implantation failure. What is the most common cause of implantation failure in couples like this undergoing IVF?

a. A very thick endometrium
b. Chromosome abnormalities in the embryo
c. Immunological disorders, such as antiphospholipid syndrome
d. Luteal phase deficiency (in the form of poor support)
e. Poor-quality embryos

Answer 82

B - Chromosome abnormalities in the embryo

Aneuploidies are the most frequent cause of spontaneous miscarriages and implantation failure in couples undergoing IVF. Structural chromosome rearrangements occur as a result of simultaneous breakage of chromosomal segments that then rejoin within the same or a different chromosome.

TOG StratOG Resource

Question 83

You see a couple in the Gynaecology clinic with subfertility of 18 months’ duration. The woman, who is generally healthy, has a BMI of 24 kg/m2 and is ovulating normally as evidenced by 21-day progesterone test. The man, who is a smoker, has a BMI of 44 kg/m2. What is the likely impact of his high BMI on their fertility?

a. Alters lipid content of seminal plasma
b. Associated with hypothermia of the testicles
c. Causes erectile dysfunction
d. Increases libido
e. Production of immature spermatozoa

Answer 83

C - Causes erectile dysfunction

Obesity can impair fertility in both men and women. In the man, it can contribute to subfertility by causing DNA damage to sperm, decreasing libido and causing erectile dysfunction. In the woman, it alters the follicular environment and leads to oocyte incompetence and suboptimal embryo quality, impairing implantation by negatively influencing the endometrium.

TOG StratOG Resource

Question 84

A 30-year-old woman is on the waiting list for IVF treatment and has been found to have a low ovarian reserve. What is the implication of this to the woman with regards to her IVF?

a. An increased likelihood of cycle cancellation
b. High miscarriage rates
c. Increased risk of aneuploidy
d. Low pregnancy rates
e. Poor response to gonadotrophins

Answer 84

A - An increased likelihood of cycle cancellation

A woman’s age remains the single most important factor determining reproductive outcome; ovarian reserve can only predict ovarian response in an assisted reproductive technology cycle. Younger women with low ovarian reserve are more likely to have cycle cancellation caused by poor oocyte yield in IVF, but once the oocytes are retrieved they have almost normal pregnancy rates.

TOG StratOG Resource

Question 85

You are seeing a 29-year-old in the clinic for counselling. She has had four midtrimester miscarriages and the last two all followed a failed vaginal cerclage (one a McDonald and the other a Shirodkar). When she was examined at her last clinic visit there was very little vaginal cervix. She is now 6 weeks pregnant. What would be the approach for minimising the risk of miscarriage in this woman?

a. Offer a transabdominal cerclage at 10–11 weeks
b. Offer an abdominal cerclage at this gestation
c. Repeat McDonald suture at 14 weeks
d. Repeat Shirodkar suture at 14 weeks
e. Serial ultrasound scan and insert Shirodkar when cervix is less than 15 mm long

Answer 85

A - Offer a transabdominal cerclage at 10–11 weeks

Where vaginal cerclages have failed and the vaginal cervix is absent or, as in this case, almost nonexistent, the patient should be offered a transabdominal cerclage. Although an interval suture has advantages over one performed in pregnancy, it’s best to offer it to this patient. The best timing of the procedure is after 10–11 weeks of gestation when first trimester miscarriages from other causes must have occurred. Some practitioners will perform an early anomaly ultrasound scan at 11 weeks before performing the procedure.

TOG StratOG Resource