IVF add-ons and fertility preservation — structured oral station (12 minutes)

Opening prompt — "Tell me how you would have counselled her at age 38."

Model response — say it in this order: ^[5][6]

• "She is 38, AMH 14 pmol/L, AFC 11 — a normal responder. Realistic per-cycle yield is 8 to 12 mature oocytes. I would recommend 1 to 2 cycles aiming for 10 to 15 mature oocytes stored."
• "Cumulative live birth per patient returning at 35 to 38 is around 30 to 40% (Cobo 2016, 2021). For a 38-year-old it sits on the lower end of that band. At her age, aneuploidy is rising and not all warmed oocytes will produce a euploid embryo."^[5][6]
• "I would also counsel the three risks: no guarantee of a future live birth, the procedure complications (bleeding, infection, anaesthetic risk, rare OHSS), and the age-related decline in oocyte quality. And the cost: storage fees continue, and approximately 30 to 50% of women do not return to use their stored oocytes."^[6]

Examiner is listening for: numbers, the honest prognosis, and the three named risks. ^[5][6]

Probe 1 — "She is now 42. What do you tell her about the realistic chance with her own oocytes?"

• "The realistic chance of a live birth with her own oocytes stored at 38, used at 42, is around 5 to 15% per warmed cohort. Most of the warmed oocytes will produce aneuploid embryos by 42 because aneuploidy rates rise sharply between 38 and 42."^[6][14]
• "I would tell her that the realistic options are: (a) use her own stored oocytes with the realistic expectation of a single-digit live-birth rate per transfer and likely multiple cycles to achieve a euploid embryo; or (b) donor oocytes with donor sperm or her partner's sperm, which gives a cumulative live birth around 60 to 80% per cycle at her age. I would present both without coercion and support whichever she chooses."^[6][14]

Probe 2 — "She asks about PGT-A. How do you respond?"

• "PGT-A is rated amber on the HFEA traffic-light system. The Hyttel 2026 systematic review and meta-analysis found that PGT-A does not improve cumulative live birth per oocyte retrieval in unselected IVF populations and may be associated with increased obstetric and neonatal complications."^[7][17]
• "In her age band, PGT-A may reduce the miscarriage rate per transfer because aneuploid embryos are discarded. But it does not increase the chance of a live birth overall because embryos that would have miscarried are simply not transferred. It is useful for monogenic disease (PGT-M) and structural chromosomal rearrangements (PGT-SR) — but not as a routine add-on."^[7]

Probe 3 — "She asks about endometrial scratching. How do you respond?"

• "Endometrial scratching is rated amber on the HFEA traffic-light system. The Perera 2026 Cochrane review concluded that endometrial injury does not improve outcomes in unselected IVF populations. Some studies suggested benefit in specific subgroups but the evidence is inconsistent."^[1][17]
• "I would not recommend it as a routine. The procedure has a small risk of infection and pain, and I would not charge her out-of-pocket for an unproven adjunct."^[17][2]

Probe 4 — "If she chooses to use her own oocytes, how do you prepare the endometrium?"

• "I prepare the endometrium in a programmed (artificial) cycle — incremental oestradiol valerate 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 oral dydrogesterone 10 mg three times daily as an alternative."^[12]
• "I start progesterone 5 days before a day-5 embryo transfer (blastocyst) or 3 days before a day-3 transfer. Trigger is by hCG when the endometrium is ready, or rely on the programmed cycle without trigger."^[12]

Probe 5 — "How do you frame the honest conversation about prognosis without removing her hope?"

This is a scored communication domain, not a courtesy. Demonstrate it out loud: ^[6]

• Move to her eye level, use her name. "Let me share with you what we know and what we do not know. At 38, the chance of a live birth from your stored oocytes is around one in three. At 42 with those same oocytes, the chance is closer to one in ten or less per transfer — because the eggs have aged with you."
• "I want to give you the most accurate information so that you can make the decision that is right for you. Some women in your situation choose to use their own oocytes knowing the odds; some choose donor oocytes, which gives a much higher chance. Both are valid choices."
• Acknowledge her feelings, keep her partner informed, allocate a staff member to support them.
• Commit to follow-up: "Whatever you decide, we will support you with the next step. I will arrange a follow-up appointment and the donor-oocyte information pack if you would like to read it."^[6]