Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG) Subfertility, Contraception and Sexual Health Syllabus

Subfertility, Contraception and Sexual Health syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Subfertility, Contraception and Sexual Health in Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG), not a summary of it.

1. 1

   Subfertility and Assisted Reproduction

   5 topics

   • Investigation of the subfertile couple
     • Ovulation, tubal and semen assessment
   • Ovulation induction and ovarian stimulation
   • Assisted conception techniques
     • IVF, ICSI and embryo transfer
     • Ovarian hyperstimulation syndrome
   • Tubal and male factor subfertility
   • Fertility preservation and donor gametes
2. 2

   Contraception and Abortion Care

   5 topics

   • Hormonal contraception
     • Combined and progestogen-only methods
     • UKMEC eligibility criteria
   • Long-acting reversible contraception
     • Intrauterine devices and systems
     • Implants and injectables
   • Emergency contraception and sterilisation
   • Termination of pregnancy: medical and surgical methods
   • Post-abortion and contraception counselling
3. 3

   Early Pregnancy and Recurrent Loss

   4 topics

   • Miscarriage: diagnosis and management
     • Threatened, missed and incomplete miscarriage
     • Expectant, medical and surgical management
   • Ectopic pregnancy
     • Diagnosis, sites and management options
   • Recurrent pregnancy loss investigation
   • Gestational trophoblastic disease
4. 4

   Sexual and Reproductive Health

   4 topics

   • Sexually transmitted infections
     • Chlamydia, gonorrhoea and pelvic inflammatory disease
     • Genital herpes, warts and syphilis
   • Vaginal discharge and genital infections
   • Psychosexual problems and female sexual dysfunction
   • Female genital mutilation: care and legal duties

Subfertility, Contraception and Sexual Health flashcards for Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG)

19 of 52 cards from the Subfertility, Contraception and Sexual Health deck — real questions with worked answers.

1. How is subfertility (infertility) defined in terms of duration of trying to conceive?

   Failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse (every 2-3 days). Early referral/investigation is warranted if the woman is over 36, or there is a known cause of infertility or history of predisposing factors.

2. What baseline blood test confirms ovulation, and when is it taken?

   Mid-luteal phase serum progesterone, taken 7 days before the expected period (i.e. day 21 of a 28-day cycle). A level $> 30\ \text{nmol/L}$ confirms ovulation.

3. What is the first-line test to assess tubal patency in a woman with no comorbidities, and the alternative when comorbidities (e.g. PID, endometriosis) are suspected?

   First-line: hysterosalpingography (HSG), or HyCoSy (hystero-contrast sonography). If comorbidities are suspected, laparoscopy and dye test is preferred as it also allows assessment and treatment of pelvic pathology.

4. List the key parameters and 2010 WHO lower reference limits for a normal semen analysis (volume, concentration, total count, motility, morphology).

   Volume $\geq 1.5\ \text{mL}$; sperm concentration $\geq 15 \times 10^{6}/\text{mL}$; total sperm number $\geq 39 \times 10^{6}$ per ejaculate; total motility $\geq 40\%$ (progressive $\geq 32\%$); normal morphology $\geq 4\%$.

5. If the first semen analysis is abnormal, when should it be repeated?

   Repeat 3 months later (to allow one full spermatogenesis cycle, ~74 days). If a gross deficiency (azoospermia or severe oligozoospermia) is found, repeat as soon as possible.

6. What is the WHO classification of ovulatory disorders into 3 groups?

   Group I: hypothalamic-pituitary failure (hypogonadotropic hypogonadism, low FSH/LH/oestrogen) ~10%. Group II: hypothalamic-pituitary-ovarian dysfunction (normogonadotropic normo-oestrogenic, e.g. PCOS) ~85%. Group III: ovarian failure (hypergonadotropic hypogonadism, high FSH, low oestrogen) ~5%.

7. What is first-line pharmacological ovulation induction for anovulatory PCOS, and a commonly used alternative?

   Letrozole (aromatase inhibitor) is now first-line. Clomifene citrate is an alternative. Metformin may be added or used, particularly with insulin resistance. Gonadotropins or laparoscopic ovarian drilling are second-line.

8. What lifestyle intervention is recommended first for anovulatory women with PCOS and a raised BMI?

   Weight loss; a loss of 5-10% of body weight can restore ovulation. Advise BMI reduction to $< 30\ \text{kg/m}^{2}$ before fertility treatment, as this also improves response and reduces miscarriage risk.

9. What are the WHO/NICE criteria defining Ovarian Hyperstimulation Syndrome (OHSS) severity as 'severe'?

   Severe OHSS: clinical ascites (and/or hydrothorax), oliguria, haemoconcentration with haematocrit $> 0.45$, hyponatraemia, hypo-osmolality, hypoproteinaemia. Critical OHSS adds tense ascites, haematocrit $> 0.55$, WCC $> 25 \times 10^{9}/\text{L}$, oligo/anuria, thromboembolism, ARDS.

10. What is the main mediator and key risk factors for OHSS?

    Mediated by VEGF causing increased capillary permeability, triggered by hCG. Risk factors: young age, low BMI, PCOS, high antral follicle count, high AMH, previous OHSS, high oestradiol, large number of follicles/oocytes, and use of hCG trigger / pregnancy.

11. In IVF, what is the role of GnRH agonists versus antagonists in controlled ovarian stimulation?

    Both prevent a premature LH surge. GnRH agonists (long protocol) initially cause a flare then downregulation. GnRH antagonists give immediate suppression (shorter protocol) and allow a GnRH agonist trigger, which substantially reduces OHSS risk.

12. What does ICSI (intracytoplasmic sperm injection) involve and what is its main indication?

    A single sperm is injected directly into the cytoplasm of an oocyte. Main indication: severe male factor subfertility (low count/motility/morphology), surgically retrieved sperm (azoospermia), or previous failed fertilisation with conventional IVF.

13. Name two surgical sperm retrieval techniques and the type of azoospermia each is used for.

    PESA/MESA (percutaneous/microsurgical epididymal sperm aspiration) for obstructive azoospermia; TESE/micro-TESE (testicular sperm extraction) for non-obstructive azoospermia.

14. What is the most common genetic cause of obstructive azoospermia, and what test should be offered before ICSI?

    Congenital bilateral absence of the vas deferens (CBAVD), associated with CFTR (cystic fibrosis) gene mutations. Offer CFTR mutation screening to the man and his partner before ICSI.

15. Which genetic tests are indicated in non-obstructive azoospermia or severe oligozoospermia?

    Karyotype (e.g. for Klinefelter 47,XXY) and Y-chromosome microdeletion analysis (AZFa, AZFb, AZFc regions).

16. What is the standard method of fertility preservation for women before gonadotoxic cancer treatment, and the established option for men?

    Women: oocyte or embryo cryopreservation after ovarian stimulation; ovarian tissue cryopreservation if no time for stimulation or pre-pubertal. Men: sperm cryopreservation (semen banking) before treatment.

17. What are the UK statutory storage limits and consent considerations for donor gametes/embryos under HFEA rules?

    Under HFEA (2022 change), gametes and embryos can be stored for up to 55 years with renewed consent every 10 years. Donors are identifiable: donor-conceived people can access identifying donor information at age 18.

18. By what mechanisms do combined hormonal contraceptives (CHC) prevent pregnancy?

    Primary: inhibition of ovulation by suppressing the hypothalamic-pituitary axis (suppressing FSH/LH and the LH surge). Secondary: thickening cervical mucus and thinning the endometrium.

19. What is the failure rate of the combined oral contraceptive pill with perfect use versus typical use?

    Perfect use $< 1\%$ (about 0.3 per 100 women-years); typical use about 9 per 100 women-years in the first year.

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