IVF add-ons and fertility preservation — structured SAQ (15 marks)

(a) Per-cycle yield, number of cycles, and age-specific prognosis (4 marks)

One mark per correct element. ^[5][6]

• Per-cycle yield at 38: typically 8 to 12 mature (MII) oocytes retrieved per cycle in a normal responder with AMH 14 pmol/L and AFC 11.^[5]
• Number of cycles: 1 to 2 stimulation cycles — aim for 10 to 15 mature oocytes stored in total, although more is preferable in her age band.^[6]
• Cumulative live birth per patient returning at 35 to 38: around 30 to 40% (Cobo 2016, 2021). For a 38-year-old, the expected cumulative live birth is on the lower end of that band and drops steeply after 38.^[6][14]
• Honest framing: at 38, the realistic chance of a live birth from her own stored oocytes is one in three to one in five per patient returning; she should be counselled that not all oocytes survive thaw and not all patients return.^[5][6]

(b) Three risks of the procedure and how you counsel her (3 marks)

• No guarantee of a future live birth — at her age, the per-warmed-oocyte live birth rate is around 4 to 8%, and 30 to 50% of women do not return to use their stored oocytes. Storage costs continue until disposition. Discuss that social egg freezing is insurance, not a guarantee.^[5][6]
• Procedure-related complications — bleeding, infection, anaesthetic risk at egg collection; ovarian hyperstimulation syndrome is rare in a normal responder at her age (under 2% severe) but not zero.^[6]
• Age-related decline in oocyte quality — even with successful storage and thaw, aneuploidy rates rise sharply after 38, so most warmed-and-fertilised oocytes will not produce a euploid embryo. Genetic counselling about age-related miscarriage and aneuploidy is essential before she consents.^[6]

(c) Preparation of the endometrium and expected live-birth at 42 with her own oocytes (4 marks)

• Endometrial preparation for frozen embryo transfer — a programmed (artificial) cycle with incremental oestradiol valerate (typically 4 to 6 mg daily orally or transdermally), ultrasound monitoring of endometrial thickness (target over 7 mm, ideally 8 to 10 mm), and luteal phase support with vaginal micronised progesterone 200 mg three times daily (or 400 mg twice daily), or oral dydrogesterone 10 mg three times daily as an alternative. Start progesterone 5 days before a day-5 embryo transfer (blastocyst) or 3 days before a day-3 transfer.^[12]
• Trigger: ovulation trigger with hCG when the endometrium is ready, or rely on the programmed cycle without trigger.^[12]
• Expected live birth at 42 with her own oocytes stored at 38: around 5 to 15% per warmed cohort — most oocytes stored at 38 will produce aneuploid embryos by the time she is 42, because the aneuploidy rate rises sharply between 38 and 42. Honest counselling is that the chance per transfer is single-digit and the realistic conversation includes donor oocytes.^[6][14]
• Alternative: donor oocytes with her partner's sperm give a much higher cumulative live birth (around 60 to 80% per cycle in this age band), and the legal framework in Australia and the UK allows her to use donor sperm with her own previously-stored donor sperm choice or with her current partner's sperm.^[6]

(d) Evidence-based response on IVF add-ons (4 marks)

• PGT-A: the Hyttel 2026 systematic review and meta-analysis found that PGT-A does not improve cumulative live birth per oocyte retrieval in an unselected IVF population and may be associated with increased obstetric and neonatal complications. In her age band (over 38), PGT-A may reduce miscarriage but does not increase the chance of a live birth because embryos that would have miscarried are discarded. Counsel that PGT-A is useful for monogenic disease (PGT-M) and structural rearrangements (PGT-SR), but not as a routine add-on for aneuploidy screening.^[7][17]
• Endometrial scratching: the Perera 2026 Cochrane review concluded that endometrial injury does not improve outcomes in unselected IVF populations. It is rated amber on the HFEA traffic-light system — some studies, no consistent benefit, possible harm and inconvenience. Counsel that the evidence is weak and the procedure should not be offered as a routine.^[1][17]
• Honest framing: refer to the HFEA traffic-light system and the ESHRE good-practice recommendations on add-ons; document the discussion and obtain explicit informed consent before any add-on.^[17][2]