Assisted reproductive technology — structured oral station (12 minutes)

Opening prompt — "Outline your plan from this point."

Model response — say it in this order: ^[1][2]

• "They meet the definition of infertility — failure to conceive after two years — and the indication for ART is severe male factor, which means ICSI rather than conventional IVF, first described by Palermo in 1992."
• "Before treatment I would complete the work-up — repeat the semen analysis, arrange male hormonal and genetic assessment (karyotype, cystic fibrosis carrier status, Y-microdeletion), confirm her ovarian reserve and uterine cavity, and do infectious-disease screening."
• "I would walk them through the staged pathway — suppress, stimulate, trigger, retrieve, fertilise by ICSI, culture, transfer with luteal support — and counsel them honestly on age-stratified cumulative success."^[2]

Examiner is listening for: the pathway named in order, the ICSI indication justified, and honest age-aware counselling. ^[1]

Probe 1 — "Which stimulation protocol would you choose, and why?"

• "A GnRH antagonist protocol, not the long agonist. The Cochrane review shows a substantial reduction in OHSS with the antagonist — OR 0.61 — without lowering live birth, which was comparable (OR 1.02)."^[3]
• "The decisive advantage is that the antagonist protocol permits a GnRH agonist trigger instead of hCG, which is the single most powerful lever against early OHSS. I would individualise her gonadotrophin dose by age, BMI, antral follicle count and prior response."^[3]

Probe 2 — "How many embryos would you transfer, and what luteal support?"

• "Elective single embryo transfer. ASRM and SART refine the number of embryos to transfer specifically to promote singleton gestation and reduce multiple pregnancies — and multiple pregnancy is the single biggest iatrogenic risk of ART."^[6]
• "For luteal support, progesterone, never hCG — the Cochrane review found hCG carries a higher OHSS risk and should be avoided; progesterone is the best option."^[5]

Probe 3 — "They are 38 and 40. What is their realistic chance of a live birth?"

• "I would counsel on cumulative live birth across a full course of treatment, because that is what matters to them. Malizia's data show that at 40 or older, cumulative live birth after up to six cycles was 23% conservative to 42% optimistic, versus 65% to 86% under 35."^[4]
• "The honest message — which the authors state — is that IVF may largely overcome infertility in younger women, but it does not reverse the age-dependent decline. Given her age, I would discuss the option of donor oocytes early rather than late."^[4]

Probe 4 — "She asks whether her baby will be healthy. How do you answer?"

This is a scored domain, not a courtesy. Demonstrate it out loud: ^[1]

• Answer honestly and proportionately: "ART singletons have slightly higher perinatal risk than naturally conceived singletons — longer birth admissions and a bit more hospital use in early childhood — but these differences are far smaller than the risks of an ART multiple birth, and much of it reflects the subfertility itself, not the technique."^[6]
• "The single biggest thing we can do to protect the pregnancy is to transfer one embryo, so you carry a singleton rather than twins."
• Offer written information and a follow-up counselling visit; acknowledge the emotional weight without minimising the real, if modest, risks.

Probe 5 — "Name the complications of ART you would warn them about."

• "OHSS — the iatrogenic emergency of stimulation; we prevent it upstream with the antagonist protocol and agonist trigger, and I would teach them the warning symptoms — abdominal distension, breathlessness, reduced urine output."^[3]
• "Multiple pregnancy — prevented by elective single embryo transfer; and the procedural risks of retrieval — bleeding, infection, ovarian torsion and anaesthetic events."^[6]
• "And the slightly higher perinatal risk of ART singletons, much of it attributable to the underlying subfertility."^[6]