Infertility — structured oral station (12 minutes)

Opening prompt — "What does this semen analysis tell you, and what is your next step?"

Model response — apply the WHO reference values:

• "NICE compares semen analysis with WHO reference values: volume 1.4 ml or more, concentration 16 million per ml or more, progressive motility 30% or more and normal forms 4% or more. This sample has a normal volume but low concentration, progressive motility and morphology, so it is abnormal."^[6]
• "NICE advises a repeat confirmatory test after an abnormal first analysis, ideally 3 months later to allow the cycle of spermatozoa formation to be completed, or as soon as possible if there is azoospermia or severe oligozoospermia."^[6]
• "Both partners are investigated: NICE offers both partners clinical assessment and investigation after a year of unprotected intercourse without conception."^[5]
• "For her: a mid-luteal progesterone to confirm ovulation even with regular cycles, and hysterosalpingography to screen for tubal occlusion if she has no known comorbidity."^[6]

Examiner is listening for: the reference values, the repeat interval, and investigation of both partners.

Probe 1 — "The repeat semen analysis is again abnormal. What is your male-factor workup?"

• "With 2 or more abnormal analyses, NICE offers examination of the scrotum and testes and suggests considering serum testosterone and gonadotrophins."^[6]
• "Genetic tests depend on the result: Y chromosome microdeletion for idiopathic azoospermia or a concentration under 1 million per ml; CFTR for idiopathic suspected obstructive azoospermia or a vasal abnormality; karyotype for idiopathic azoospermia, and consider it with a persistent concentration under 5 million per ml; genetic counselling when a specific defect is found."^[6]

Probe 2 — "Which investigations would you NOT order?"

• "NICE says do not offer routine antisperm antibody testing, do not test sperm DNA fragmentation, do not routinely use post-coital testing because it has no predictive value on pregnancy rate, and do not use AMH to predict spontaneous pregnancy."^[6]

Probe 3 — "Her workup is normal. How do you counsel them about male-factor treatment?"

• "NICE says to consider gonadotrophin or anti-oestrogen therapy for impaired semen parameters without hypogonadotropic hypogonadism only as part of a clinical trial, not to offer androgens, and not to offer supplements or antioxidants to improve sperm DNA integrity."^[7]
• "If he has a clinically detected varicocele and reduced semen parameters while they are trying to conceive spontaneously, radiological or surgical treatment can be considered."^[7]

Probe 4 — "What would change if her AMH came back low?"

• "NICE uses AMH or antral follicle count to predict ovarian response and inform counselling about the likelihood of live birth with assisted conception, not to predict spontaneous pregnancy."^[6]
• "In the AMIGOS stimulated-IUI cohort, AMH did not predict pregnancy."^[4]

Probe 5 — "She is distressed and asks 'does this mean we'll never have children?'"

This is a scored communication domain. Demonstrate it out loud:

• Move to her eye level, use her name, acknowledge the fear.
• "Over 80% of couples conceive within a year when the woman is under 40, and about half of the rest conceive in the second year; we will plan the next steps together."^[9]

Probe 6 — "How would your approach differ if she were 41?"

• "NICE offers specialist referral at presentation when the woman is 36 or over, so I would not wait."^[5]
• "Female fertility declines with age, and maternal age is the initial predictor of the chance of pregnancy, spontaneously or with IVF."^[6][9]