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

How is the progestogen-only pill (traditional vs desogestrel) missed-pill window defined?

Traditional POP: 'late' if taken more than 3 hours after the usual time. Desogestrel POP: window is 12 hours. Drospirenone POP has a 24-hour window. If late, take the pill and use condoms/abstain for 48 hours.

Compare the two main types of long-acting reversible contraception (LARC) intrauterine devices.

Copper IUD (Cu-IUD): non-hormonal, primary action is spermicidal/toxic to ova and sperm plus inhibits fertilisation; lasts 5-10 years. Levonorgestrel IUS (e.g. Mirena): thickens cervical mucus, thins endometrium, may suppress ovulation; lasts 5-8 years and reduces menstrual loss.

What are the failure rates (per 100 women-years) of the etonogestrel implant, IUS, and Cu-IUD?

Implant: $< 0.05\%$ (most effective). LNG-IUS: $< 0.5\%$ (about 0.2%). Cu-IUD: $< 1\%$ (about 0.8%). All LARCs are more effective than user-dependent methods.

What are the three methods of emergency contraception and their timing windows?

Copper IUD: most effective, up to 120 hours (5 days) after UPSI or up to 5 days after earliest expected ovulation. Ulipristal acetate (UPA) 30 mg: up to 120 hours. Levonorgestrel 1.5 mg: licensed up to 72 hours (can be used up to 96h off-licence).

Why is the copper IUD the most effective emergency contraception?

It works by directly toxic effects on sperm and ova and prevents implantation, so it is not dependent on the timing of ovulation. Pregnancy rate is $< 0.1\%$, far lower than oral methods which only delay ovulation.

What is the key interaction to advise regarding ulipristal acetate (UPA) and progestogen?

UPA is a progesterone receptor modulator; progestogens reduce its efficacy. Avoid starting/restarting hormonal contraception for 5 days after UPA, and UPA should not be used if a progestogen was taken in the previous 7 days. Use condoms in the interim.

Compare the failure rates of male and female sterilisation.

Male sterilisation (vasectomy): lifetime failure ~1 in 2000. Female sterilisation (tubal occlusion, e.g. Filshie clips): lifetime failure ~1 in 200. Vasectomy is more effective, safer and cheaper but requires post-procedure semen analysis confirmation.

How is success of a vasectomy confirmed and contraception continued?

Continue alternative contraception until azoospermia confirmed. Semen analysis is performed at about 12 weeks (and after ~20 ejaculations); clearance is given when azoospermia (or special clearance with $< 100{,}000$ non-motile sperm/mL) is confirmed.

What gestational age limits and key regulatory clause govern medical termination of pregnancy in Great Britain under the Abortion Act 1967 (as amended)?

Most TOP performed under Clause C (risk to physical/mental health of woman greater than continuing, up to 24 weeks). Two registered doctors must sign (HSA1 form). No upper limit applies for grounds A (risk to woman's life), B (grave permanent injury) and E (substantial fetal abnormality).

What is the standard medical abortion regimen (mifepristone + misoprostol)?

Mifepristone 200 mg orally (antiprogestogen) followed 24-48 hours later by misoprostol (prostaglandin E1 analogue). Below 10 weeks misoprostol 800 mcg vaginally/sublingually/buccally; above 10 weeks repeated misoprostol doses are given.

What surgical methods are used for termination of pregnancy by gestation?

Up to ~14 weeks: vacuum (suction) aspiration. From ~14-24 weeks: dilatation and evacuation (D&E), usually with cervical preparation. Cervical priming with misoprostol (or mifepristone/osmotic dilators) reduces complications.

What anti-D and infection prophylaxis is recommended around surgical TOP?

Give anti-D immunoglobulin to non-sensitised RhD-negative women having surgical abortion (and medical abortion after ~10 weeks). Provide prophylactic antibiotics or test-and-treat for chlamydia to reduce post-abortion pelvic infection.

When can contraception be started after an abortion, including IUD/IUS and implants?

All methods can be started immediately. An IUD/IUS can be inserted at the time of surgical abortion or immediately after a medical abortion is complete. The implant and hormonal methods can begin on the day of abortion, providing immediate cover.

Define miscarriage and the types (threatened, inevitable, incomplete, complete, missed).

Miscarriage: loss of pregnancy before 24 weeks. Threatened: bleeding, closed os, viable. Inevitable: bleeding, open os. Incomplete: products partially expelled, open os. Complete: products fully expelled, closed os, empty uterus. Missed (delayed): fetus died, no/closed os, retained in utero.

What ultrasound criteria confirm an early pregnancy loss (missed miscarriage) on TVUS?

Mean gestational sac diameter $\geq 25\ \text{mm}$ with no fetal pole, OR crown-rump length $\geq 7\ \text{mm}$ with no fetal heartbeat. If below these thresholds, rescan after 7-14 days before confirming.

What are the three management options for miscarriage?

Expectant management (wait up to 7-14 days, first-line if no complications). Medical management (misoprostol $\pm$ mifepristone). Surgical management (manual vacuum aspiration under local or surgical evacuation under GA), indicated for heavy bleeding, infection, or patient preference.

How is a pregnancy of unknown location (PUL) evaluated using serum hCG?

With no pregnancy seen on TVUS, serial serum hCG measured 48 hours apart. A rise $> 63\%$ suggests likely intrauterine pregnancy; a fall $> 50\%$ suggests failing PUL; suboptimal change (between these) suggests possible ectopic and needs review.

What is the most common site of ectopic pregnancy and the classic clinical triad?

Most common site: ampulla of the fallopian tube (~70%). Classic triad: amenorrhoea/positive pregnancy test, abdominal/pelvic pain, and vaginal bleeding. Shoulder-tip pain and collapse suggest rupture/haemoperitoneum.

What are the criteria for methotrexate (medical) management of an ectopic pregnancy?

Suitable if: clinically stable, minimal/no pain, unruptured ectopic $< 35\ \text{mm}$ with no fetal heartbeat, serum hCG $< 1500\ \text{IU/L}$ (can consider up to 5000), no intrauterine pregnancy, and able to attend follow-up. Methotrexate $50\ \text{mg/m}^{2}$ IM.

What is the methotrexate follow-up protocol for ectopic pregnancy?

Measure serum hCG on days 4 and 7. Expect a fall of $\geq 15\%$ between days 4 and 7; then weekly hCG until negative. A second dose is given (up to ~15%) if the fall is inadequate. Advise avoiding pregnancy for 3 months after methotrexate.

When is surgical management (laparoscopic salpingectomy vs salpingotomy) chosen for ectopic pregnancy?

Surgery for haemodynamic instability, significant pain, large ectopic/fetal heartbeat, or high hCG. Salpingectomy is preferred if the contralateral tube is healthy. Salpingotomy is considered if the other tube is damaged (to preserve fertility) but carries persistent trophoblast risk.

How is recurrent miscarriage defined and what are the key investigable causes?

Traditionally 3 or more consecutive miscarriages (some guidance now investigates after 2). Causes: antiphospholipid syndrome, parental balanced chromosomal translocations, uterine anomalies (e.g. septate uterus), cervical insufficiency, thrombophilias, and endocrine/PCOS factors.

What are the diagnostic criteria for antiphospholipid syndrome and its treatment in pregnancy?

One clinical (vascular thrombosis or pregnancy morbidity) plus one laboratory criterion: lupus anticoagulant, anticardiolipin antibodies, or anti-$\beta_2$-glycoprotein-I antibodies, positive on 2 occasions $\geq 12$ weeks apart. Treat with low-dose aspirin plus LMWH in pregnancy.

Classify gestational trophoblastic disease into its main categories.

Hydatidiform mole: complete (diploid, paternal origin, $46,\text{XX}$ from empty ovum, no fetal tissue) and partial (triploid, $69,\text{XXX/XXY}$, fetal tissue present). Gestational trophoblastic neoplasia: invasive mole, choriocarcinoma, placental-site trophoblastic tumour, epithelioid trophoblastic tumour.

What is the typical clinical and ultrasound presentation of a complete hydatidiform mole?

Irregular vaginal bleeding, uterus large for dates, very high hCG, hyperemesis, early pre-eclampsia, hyperthyroidism. Ultrasound shows a 'snowstorm' or 'bunch of grapes' appearance with no fetus. Diagnosis confirmed histologically after uterine evacuation.

How is molar pregnancy followed up and when is chemotherapy indicated?

Register at a trophoblastic screening centre with serial serum/urine hCG monitoring. Chemotherapy is indicated for gestational trophoblastic neoplasia (e.g. plateauing/rising hCG, metastases). Avoid pregnancy until hCG normalises and for the recommended follow-up period.

What is the most common curable STI in the UK, its main complication, and recommended treatment?

Chlamydia trachomatis (often asymptomatic). Complications include PID, tubal factor infertility, ectopic pregnancy and chronic pelvic pain. First-line treatment: doxycycline 100 mg twice daily for 7 days (azithromycin if doxycycline contraindicated, e.g. pregnancy).

What organism causes the most common cause of abnormal vaginal discharge, and what are its diagnostic (Amsel) criteria?

Bacterial vaginosis (overgrowth of Gardnerella vaginalis/anaerobes). Amsel criteria (3 of 4): thin white-grey homogeneous discharge; vaginal pH $> 4.5$; positive whiff/amine test on adding KOH; clue cells on microscopy. Treat with metronidazole.

Differentiate the discharge and pH findings of bacterial vaginosis, candidiasis and trichomoniasis.

BV: thin grey, fishy odour, pH $> 4.5$, clue cells. Candida: thick white 'cottage cheese', itch, normal pH $< 4.5$, hyphae/spores. Trichomonas vaginalis: frothy yellow-green, offensive, pH $> 4.5$, 'strawberry cervix', motile flagellated protozoa on wet mount; treat with metronidazole.

What is vaginismus and the first-line management for female sexual dysfunction of this type?

Vaginismus is involuntary spasm of the pelvic floor/perivaginal muscles causing painful or impossible penetration. Management: education, sensate focus therapy, pelvic floor relaxation, use of vaginal trainers/dilators, and psychosexual counselling/cognitive behavioural therapy.

What are the WHO classification types of female genital mutilation (FGM)?

Type 1: clitoridectomy (partial/total removal of clitoral glans). Type 2: excision (removal of clitoris and labia minora $\pm$ labia majora). Type 3: infibulation (narrowing of vaginal opening by creating a covering seal). Type 4: all other harmful procedures (pricking, piercing, cauterising).

What are the UK legal and safeguarding duties of a clinician regarding FGM?

FGM is illegal (FGM Act 2003 / Serious Crime Act 2015). Mandatory reporting: regulated professionals must report to the police any case of FGM in a girl under 18 (known or disclosed). Record FGM in records, complete the FGM Enhanced Dataset, and follow safeguarding/risk-assessment for at-risk girls. Re-infibulation is illegal.