Subfertility Flashcards
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
D – Ovulation induction with clomiphene citrate
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
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.
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%
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.
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%
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.
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%
B - 50%
Couples using artificial insemination may be advised that 50% will conceive within 6 cycles and 75% within 12
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%
D - 75%
Couples using artificial insemination may be advised that 50% will conceive within 6 cycles and 75% within 12
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
B - 12 months
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
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.
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
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
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
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
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
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
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
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
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
D - 3 months
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
E - Age of female partner
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
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
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
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
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
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
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
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.
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
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.
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
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.
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
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.
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
B - 4 weeks
Women should be advised to avoid pregnancy for 4 weeks following rubella/MMR vaccination
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
D - Gonadotrophin injections
Much like in females, male hypogonadotrophic hypogonadism may be treated with gonadotrophins
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
B - 6 cycles
Ultrasound monitoring during the first cycle to ensure the dose given minimises the risk of multiple pregnancy is advised
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
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)
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
C - Bromocriptine
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
D - Laparoscopic bilateral salpingectomy
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
D - IVF
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
C - 5mm
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
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
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
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
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
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
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
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
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
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
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
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
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
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.
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
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’.
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
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’
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
B - Moderate intensity for 90 minutes 5 days a week
TOG 2017
What is the mortality rate associated with bariatric surgery?
a. 1%
b. 2-3%
c. 4-5%
d. 7-8%
e. 10%
A - 1%
TOG 2017
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
B - 12 months
TOG 2017
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
C - <30
TOG 2017
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
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
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
E - Moderate intensity for at least 60−90 minutes on five or more occasions each week
TOG 2017
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
A - Endometriosis
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
D - 10-20
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
E - Urinary hCG
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
D - 64 cell
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
A - 1
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%
B - 10%
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
D - 14 days
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
C - 10 days
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
D - 20x
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
E - 8 in 1000
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
E - None of the above
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
D - Maternal age
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%
D - 67%
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
C - Increase the clinical pregnancy rate more than four-fold
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
A - Administer GnRH agonist for the maturation trigger
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%
B - 2-10%
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
E - Does not have any effect on ovarian reserve
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
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
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
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
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%
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
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
E - Pelvic radiotherapy
TOG 2016
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%
B - 5-10%
The rate of premature menopause is quoted at ~8% by the CCSS
TOG 2016
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
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
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
B - Extravillous trophoblast
HLA A, B and C are expressed on all nucleated cells with the singular exception of extravillous trophoblast
TOG 2016
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
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
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
D - Cystic fibrosis
European caucasians - CF
Worldwide - Beta-Thalassamiea
TOG 2016
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
E - Beta-thalassaemia
TOG 2016
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
B - Chromosome 6
TOG 2016
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
D - 3 in 16
TOG 2016
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
E - Blastocyst
TOG 2016
What proportion of infertility is – after investigation – unexplained?
a. 5-10%
b. 15-20%
c. 30-40%
d. 60-70%
e. 85-90%
C - 30-40%
TOG 2016
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%
B - Up to 4%
TOG 2016
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
D - Maternal age
TOG 2016
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%
D - 30%
Endometriosis will be found at laparoscopy in 30% of asymptomatic women during investigation for subfertility
TOG 2016
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
C - >15 million/ml
TOG 2016
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
E - Any of the above
Unlike FSH which is timing specific, AMH may be measured at any stage in the menstrual cycle
TOG 2016
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
B - 2 years
TOG 2016
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
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
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
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
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
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
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
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
