The following statement(s) about unexplained infertility is/are true:

• a)
  

  The term ‘unexplained infertility’ refers to couples in whom standard investigations (e.g. assessment for ovulation, tubal patency and semen analysis) are normal.

  
  
• b)
  

  The main aetiological factor underlying unexplained infertility is infection.

  
  
• c)
  

  Couples with unexplained infertility have a low chance of spontaneous pregnancies compared with infertility due to other causes.

  
  
• d)
  

  Laparoscopy is necessary for diagnosing unexplained infertility.

  
  
• e)
  

  Infertility is unexplained in one-quarter of all infertile couples.

The following is/are true about treatment options for unexplained infertility:

• a)
  

  Clomiphene citrate improves outcomes in unexplained infertility by correcting subtle ovulatory dysfunctions.

  
  
• b)
  

  Unstimulated intrauterine insemination (IUI) is an effective treatment for unexplained infertility.

  
  
• c)
  

  Super ovulation with IUI and unstimulated IUI are equally effective in unexplained infertility.

  
  
• d)
  

  Super ovulation with IUI is associated with a higher risk of multiple pregnancies.

  
  
• e)
  

  In-vitro fertilisation (IVF) is an effective option for long-standing unexplained infertility.

The following feature(s) of an ejaculate can be interpreted correctly as follows:

• a)
  

  A man with 14% normal forms in 1992 and 4% in 2011 does not have evidence of testicular dysgenesis.

  
  
• b)
  

  With a sperm concentration of 12 × 10 ⁶ and 31% progressively motile sperm, a man should be told he is sub-fertile and considered for intrauterine insemination (IUI) or in-vitro fertilisation (IVF).

  
  
• c)
  

  A sperm morphology of 0% is consistent with globozoospermia and usually associated with no spontaneous conception.

  
  
• d)
  

  High numbers of leucocytes suggest infection and antibiotics should be given without the need for further investigation.

  
  
• e)
  

  A sperm concentration of greater than 50 × 10 ⁶ per ml indicates normal fertility regardless of the result from any other variable.

The following statement(s) is/are true about measuring sperm DNA damage:

• a)
  

  The results correlate with the probability of early pregnancy loss in IVF and intracytoplasmic sperm injection (ICSI).

  
  
• b)
  

  Mandatory tests are now recommended as part of semen analysis.

  
  
• c)
  

  The results are meaningless as the oocyte is able to repair most types of DNA damage.

  
  
• d)
  

  IMSI selects sperm on the basis of DNA fragmentation.

  
  
• e)
  

  Cigarette smoking is a cause of DNA damage in sperm.

The binding of sperm to hyaluronic acid is the basis of a proposed sperm function test because bound sperm:

• a)
  

  Undergo the acrosome reaction and are therefore better able to undergo nuclear de-condensation after ICSI.

  
  
• b)
  

  Appear to be of superior sperm morphology.

  
  
• c)
  

  Express surface molecules that facilitate the fertilisation process.

  
  
• d)
  

  Have less residual cytoplasm.

  
  
• e)
  

  Give rise to better quality embryos, hence improvements in live birth rates.

When comparing WHO manuals from 1980 to 2010:

• a)
  

  The reference values for sperm morphology have declined from 80% in 1980 to 4% in 2010 because of the global decline in semen quality.

  
  
• b)
  

  Men with values below the 2010 threshold can be confidently defined as infertile.

  
  
• c)
  

  The minimum semen volume of ≥1.5 ml proposed in WHO 2010 is lower than previous manuals because of technical improvements in measuring ejaculate volume.

  
  
• d)
  

  A reference value for pH is not available as there is a lack of information about seminal pH in fertile men.

  
  
• e)
  

  The values for sperm viability should always be higher than those for the percentage of progressively motile sperm.

The following statement(s) is/are true about intrauterine pathology and its investigation:

• a)
  

  Hysteroscopy should be carried out routinely in the investigation of infertility.

  
  
• b)
  

  There is good evidence that intrauterine s decrease pregnancy rates.

  
  
• c)
  

  There is good evidence that submucous myomas decrease pregnancy rates.

  
  
• d)
  

  A prospective study has shown that hysteroscopic removal of a uterine septum is associated with an increased pregnancy rate.

  
  
• e)
  

  Hysteroscopic removal of severe adhesions is associated with a live birth rate in about one-third of cases.

The following statement(s) is/are true about the association between hydrosalpinx and in-vitro fertilisation (IVF) outcome:

• a)
  

  The presence of hydrosalpinx decreases the IVF pregnancy rate.

  
  
• b)
  

  Randomised trials show that removal of the hydrosalpinx is associated with increased pregnancy rate.

  
  
• c)
  

  Laparoscopic occlusion of the proximal part of the tubes increases the IVF pregnancy rate.

  
  
• d)
  

  A good study shows that hysteroscopic occlusion of the proximal part of the tubes increases the IVF pregnancy rate.

  
  
• e)
  

  Laparoscopic salpingectomy does not decrease ovarian reserve.

The following statement(s) is/are true concerning sub-fertility and its treatments:

• a)
  

  Over one-half of infertile women who underwent laparoscopic treatment of endometriosis will conceive within 1 year of surgery.

  
  
• b)
  

  The incidence of ectopic pregnancy after IVF treatment is much higher than that in the general population.

  
  
• c)
  

  Laparoscopic treatment of ovarian endometriomas with excision is associated with similar pregnancy rates than after fenestration and ablation.

  
  
• d)
  

  Laparoscopic treatment of ovarian endometriomas with excision is associated with reduced ovarian reserve.

  
  
• e)
  

  IVF pregnancy rates in women who have had surgical treatment of endometriomas and untreated women are similar.

The following statement(s) is/are true concerning sub-fertility and its treatments:

• a)
  

  Laparoscopic ovarian suspension before pelvic radiation is associated with preservation of ovarian function in up to 50% of cases.

  
  
• b)
  

  Hormonal function will resume a few weeks after laparoscopic ovarian grafting.

  
  
• c)
  

  The best method for fertility preservation in women is oocyte cryopreservation.

  
  
• d)
  

  Ovarian cryopreservation is the only alternative for fertility preservation for pre-pubertal girls.

  
  
• e)
  

  Transplantation of frozen-thawed ovarian tissue is still experimental and no live birth has been reported.

In women with hypogonadotrophic hypogonadism:

• a)
  

  Weight gain is important before contemplating fertility treatment if she is underweight.

  
  
• b)
  

  Clomiphene citrate is a recommended first-line medical treatment.

  
  
• c)
  

  Ovulation induction with recombinant follicle-stimulating hormone (FSH) alone is an effective treatment.

  
  
• d)
  

  Serum FSH and oestradiol levels are always below the normal reference range.

  
  
• e)
  

  Magnetic resonance imaging of the pituitary should be carried out to exclude an intracranial organic pathology.

In women with anovulatory subfertility secondary to polycystic ovary syndrome:

• a)
  

  Weight reduction is the first-line management in women who are obese or overweight.

  
  
• b)
  

  Clomiphene citrate is a recommended first-line medical treatment.

  
  
• c)
  

  Metformin is as effective as clomiphene citrate as a first-line medical treatment on its own.

  
  
• d)
  

  An elevated luteinising hormone: FSH ratio should be essential for confirming the diagnosis.

  
  
• e)
  

  Laparoscopic ovarian drilling should always be carried out before ovulation induction with gonadotrophin.

In management of a woman with hyperprolactinaemia:

• a)
  

  Prompt treatment with a dopamine agonist should be initiated even if she is asymptomatic.

  
  
• b)
  

  Macroprolactinaemia needs to be excluded.

  
  
• c)
  

  Magnetic resonance imaging of the pituitary is needed to look for prolactinoma if serum prolactin level is above 1000 mIU/L.

  
  
• d)
  

  Treatment should aim at normalisation of serum prolactin level regardless of her ovulatory status.

  
  
• e)
  

  Treatment with dopamine agonists can be stopped after pregnancy is confirmed unless she has a macroprolactinoma.

The following statement(s) is/are true concerning sub-fertility and its treatments:

• a)
  

  The fertility of a couple is mostly defined by the fertility of the man.

  
  
• b)
  

  In subfertile men a treatable cause is often found.

  
  
• c)
  

  Strong evidence shows that anti-oxidants improve sperm parameters in sub-fertile men.

  
  
• d)
  

  No strong evidence is available that varicocelectomy improve sperm parameters in sub-fertile men.

  
  
• e)
  

  Semen analysis is a reliable method of defining male subfertility.

The following statement(s) is/are true concerning sub-fertility and its treatments:

• a)
  

  Semen analysis is standardised by the World Health Organization.

  
  
• b)
  

  Men with a total motile sperm count below 1 million after sperm processing will never father a child spontaneously.

  
  
• c)
  

  Intracytoplasmic sperm injection (ICSI) is the treatment of first choice in men with a total motile sperm count after sperm processing between 1 and 5 million.

  
  
• d)
  

  In men with a total motile sperm count after sperm processing below 1 million intrauterine insemination should precede ICSI.

  
  
• e)
  

  In obstructive azoospermia, fine-needle aspiration is the treatment of choice when sperm are to be frozen.

Which of the following statement(s) regarding in-vitro fertilisation (IVF) treatment is/are true?

• a)
  

  A 3-month course of gonadotropin releasing hormone (GnRH) agonist administered before starting IVF has been shown to improve the ongoing pregnancy rate in women with endometriosis.

  
  
• b)
  

  A 3-month course of gonadotropin releasing hormone (GnRH) agonist administered before starting IVF has been shown to improve the ongoing pregnancy rate in women without endometriosis.

  
  
• c)
  

  IVF is indicated in women who remain infertile for 3 months after tubal surgery.

  
  
• d)
  

  Women over 40 years of age should proceed with IVF after three unsuccessful gonadotropin and intrauterine insemination (IUI) treatment cycles.

  
  
• e)
  

  The only strategy of female fertility preservation recognised by the American Society of Clinical Oncology and the American Society of Reproductive Medicine is IVF and cryopreservation of embryos.

Which of the following statement(s) about ovarian reserve testing is/are true:

• a)
  

  A recent meta-analysis has shown that clomiphene citrate challenge testing has limited predictive values.

  
  
• b)
  

  Ultrasonographic assessment of ovarian reserve includes antral follicle count, ovarian volume and blood flow.

  
  
• c)
  

  Anti-Müllerian hormone (AMH) and antral follicle count seem to be the two most accurate predictors of ovarian response to controlled ovarian hyperstimulation.

  
  
• d)
  

  Disadvantages of AMH are variation in serum levels during the menstrual cycle.

  
  
• e)
  

  Disadvantages of AMH are variation in serum levels from cycle-to-cycle.

Which of the following statement(s) about the use gonadotropin releasing hormone (GnRH) antagonists in IVF cycles is/are true?

• a)
  

  GnRH antagonist administration can be either fixed or flexible.

  
  
• b)
  

  A recent meta-analysis found pregnancy rates to be higher using the flexible GnRH antagonist protocol compared with the fixed GnRH antagonist protocol.

  
  
• c)
  

  GnRH antagonist competes with endogenous GnRH in binding to the GnRH receptors, thereby rapidly inhibiting secretion of gonadotropins.

  
  
• d)
  

  Administration of GnRH antagonists always results in complete suppression of Gn production.

  
  
• e)
  

  In the setting of high-responders, the use of GnRH antagonist has been shown to decrease the incidence of OHSS compared with GnRH-agonist-based IVF protocol.

The European Society of Human Reproduction and Embryology consensus working group’s definition of poor ovarian response include which of the following parameters?

• a)
  

  They must meet two of the three recognized criteria.

  
  
• b)
  

  Advanced maternal age (≥35 years).

  
  
• c)
  

  Previous history of poor ovarian response (fewer than three oocytes retrieved after a conventional IVF protocol).

  
  
• d)
  

  An abnormal ovarian reserve test – AFC less than five to seven follicles.

  
  
• e)
  

  An abnormal ovarian reserve test – AMH over 0.5–1.1 ng/ml.

If the maximum welfare standard is consistently applied, which of the following would be true?

• a)
  

  Only a small percentage of the population should be allowed to reproduce.

  
  
• b)
  

  Only a small percentage of the population should have access to assisted reproductive technology.

  
  
• c)
  

  Lesbian couples should be excluded from fertility treatment.

  
  
• d)
  

  Heterosexual couples should be excluded from fertility treatment.

  
  
• e)
  

  People with cancer should not have access to fertility preservation.

What is/are considered the problem(s) with the ‘no difference’ view in research on homosexual parenting?

• a)
  

  It is too pro-homosexual.

  
  
• b)
  

  It is too anti-homosexual.

  
  
• c)
  

  It starts from the wrong premise, namely that heterosexual parents are the gold standard.

  
  
• d)
  

  It allows adequate exploration of issues such as formation of gender identity in the children.

  
  
• e)
  

  It starts from the wrong hypothesis, namely that we would expect children raised by homosexual parents to be worse off than those raised by heterosexual parents.

The following is/are true regarding whether fertility preserving interventions should be offered to people with cancer:

• a)
  

  It should be offered at the patient’s request.

  
  
• b)
  

  Limited time scales make decision making more difficult.

  
  
• c)
  

  It should be offered if the risks are not prohibitively high and the utility is not prohibitively low.

  
  
• d)
  

  It should be offered if they are well-established and evidence-based.

  
  
• e)
  

  Experimental procedures should only be offered in a research context.

Fertility preservation for pre-pubertal boys and girls is ethically problematic because:

• a)
  

  Minors are unable to provide an informed consent.

  
  
• b)
  

  Parents need to provide informed consent.

  
  
• c)
  

  Their options are limited to experimental procedures.

  
  
• d)
  

  Childhood cancers, such as leukaemia, pose a specific risk for the re-introduction of malignant cells.

  
  
• e)
  

  There is no established tumour cell re-introduction identification possible.

A significantly higher risk of congenital malformations has been detected in children conceived through assisted reproductive technology. The following is/are true about assisted reproductive technology and malformations:

• a)
  

  The higher risk is probably true as it has been found in several large studies and meta-analyses.

  
  
• b)
  

  The risk of congenital malformations is particularly high after ICSI.

  
  
• c)
  

  The risk of congenital malformations is particularly high using blastocysts.

  
  
• d)
  

  The risk of congenital malformations is particularly high using cryopreserved embryos.

  
  
• e)
  

  The risk of congenital malformations is particularly high among multiple births.

Accurate pre-implantation genetic diagnosis (PGD) for a single-gene disorder requires taking into account which of the following:

• a)
  

  Quality of the biopsy.

  
  
• b)
  

  Indication for the procedure.

  
  
• c)
  

  Failure of an allele to amplify.

  
  
• d)
  

  One allele being amplified to a much greater extent than another.

  
  
• e)
  

  Double-stranded chromosomal break.

Analysis of DNA for PGD can be derived from which of the following sources?

• a)
  

  Polar body.

  
  
• b)
  

  Sperm.

  
  
• c)
  

  Acrosomes.

  
  
• d)
  

  Blastomere.

  
  
• e)
  

  Blastocyst.

The method(s) currently used for PGD aneuploidy testing is/are:

• a)
  

  Karyotype.

  
  
• b)
  

  Fluorescent in-situ hybridisation (FISH) with seven chromosome-specific probes.

  
  
• c)
  

  FISH for all 24 chromosomes.

  
  
• d)
  

  PCR.

  
  
• e)
  

  Array comparative genome hybridisation.

The following statement(s) is/are true about ovarian hyperstimulation syndrome (OHSS):

• a)
  

  The pathophysiology of OHSS is characterised by decreased capillary permeability.

  
  
• b)
  

  Human chorionic gonadotrophin (hCG) is thought to play a crucial role in the development of the syndrome.

  
  
• c)
  

  Severe cases of OHSS are usually associated with non-pregnancy cycles.

  
  
• d)
  

  Late OHSS is more likely to be severe than the early form.

  
  
• e)
  

  OHSS is self-limiting and not life-threatening.

Recognised risk factors for developing OHSS include:

• a)
  

  Smoking.

  
  
• b)
  

  Young age.

  
  
• c)
  

  Polycystic ovary syndrome.

  
  
• d)
  

  Exposure to hCG.

  
  
• e)
  

  Obesity.

The following are considered strategies for preventing OHSS:

• a)
  

  Using hCG for luteal support.

  
  
• b)
  

  Gonadotropin-releasing hormone (GnRH) antagonist protocols.

  
  
• c)
  

  Triggering ovulation by high-dose hCG.

  
  
• d)
  

  Triggering ovulation by GnRH agonist.

  
  
• e)
  

  Cryopreservation of all embryos.