IVF and ART techniques — structured oral station (12 minutes)

Opening prompt — "Tell me what you decide today."

Model response — say it in this order: ^[1][9]

• "She is a high responder on every criterion I look for — over 20 follicles, oestradiol over 3000 pg/mL, PCOS, AMH over 35 pmol/L. The risk of severe OHSS with an hCG trigger is 6 to 12%."
• "I will trigger with a GnRH agonist — leuprolide or triptorelin 0.2 mg subcutaneously, single bolus, 36 hours before oocyte retrieval. This empties the LH/CG receptor pool within hours and reduces severe OHSS to near zero."
• "I will defer fresh transfer (freeze-all) because even an agonist trigger does not eliminate OHSS in fresh transfer. I will vitrify all suitable embryos and prepare the endometrium in a programmed cycle for deferred transfer."^[1][9][10]

Examiner is listening for: high-responder recognition, named dose/route, the rationale, and the explicit freeze-all decision. ^[9]

Probe 1 — "How will you support the luteal phase, and why is progesterone alone insufficient?"

• "Vaginal micronised progesterone 200 mg three times daily from the day of retrieval through 10 to 12 weeks of gestation if pregnancy is confirmed. But after an agonist trigger I add intensive LH activity support — a small rescue dose of hCG 1500 IU subcutaneously at retrieval, or aggressive oestradiol and progesterone supplementation."^[8]
• "The agonist trigger produces only a short, self-limited LH surge lasting 24 to 36 hours. The corpora lutea are partially luteolysed. Without LH activity support, progesterone alone gives a pregnancy rate roughly half that of hCG trigger with standard support."^[1][8]

Probe 2 — "She is admitted on day 6 post-retrieval with abdominal distension, oliguria, haematocrit 52%, and 14-cm ovaries. What now?"

• "This is severe OHSS. I admit her to a high-dependency area with daily weights, abdominal girth, fluid balance, and oxygen saturation. IV crystalloid at maintenance rate, aiming for urine output over 30 mL/hour; avoid fluid overload because pulmonary oedema is a recognised iatrogenic complication."^[9]
• "Thromboprophylaxis with LMWH — enoxaparin 40 mg subcutaneously daily. Severe OHSS carries a thromboembolic risk of 1 to 2% from haemoconcentration and ascites."^[9]
• "Paracentesis if tense ascites are causing respiratory compromise or worsening oliguria. Dopamine infusion 2 to 4 micrograms/kg/min if persistent oligo-anuria despite fluids."^[9]
• "I monitor electrolytes, haematocrit, creatinine, coagulation; transvaginal ultrasound for ovarian size; chest X-ray and pulse oximetry if respiratory symptoms."^[9]

Probe 3 — "She asks why this happened. How do you counsel her?"

This is a scored communication domain, not a courtesy. Demonstrate it out loud: ^[9]

• Move to her eye level, use her name. "You have had a strong response to the stimulation — many eggs and high hormone levels — and your body has reacted by shifting fluid into your abdomen. We are giving you fluids through a drip and a blood thinner to reduce the risk of clots, and we are watching you closely."
• Acknowledge fear, keep her partner informed, allocate a staff member to support them.
• Commit to a clear plan: "We expect this to settle in 7 to 14 days. If your breathing becomes difficult or your urine output drops, we will drain the fluid from your abdomen."
• Plan the next cycle: "When you come back, we will use a slightly lower dose of stimulation medication and consider metformin. Losing 5 to 10% of your weight before the next cycle also reduces this risk."^[9]

Probe 4 — "What will you tell her about the cumulative chance of a live birth if she continues?"

• "Cumulative live birth after up to 6 IVF cycles in her age group is around 86% optimistic and 65% conservative (Malizia 2009 NEJM). The age cliff is the single most important modifier — under 35 with 8 oocytes retrieved has a 65% conservative cumulative live birth by 3 cycles. Most successful pregnancies occur within the first 3 cycles; the curve flattens after that."^[4]
• "For PCOS specifically, the antagonist protocol with agonist trigger and freeze-all preserves the cumulative live birth while removing the OHSS risk. If she does not conceive after 3 full cycles with good-prognosis embryos, the conversation turns to donor oocytes or other family-building options."^[4][9]

Probe 5 — "Why did you not use the long GnRH agonist protocol from the start?"

• "The Al-Inany 2016 Cochrane review (73 RCTs) found that the antagonist protocol gives a comparable live birth to the long agonist in an unselected IVF population, with significantly lower OHSS and shorter stimulation duration. The antagonist is the default in most modern units because it allows the GnRH agonist trigger — the substrate for the OHSS prevention bundle. The long agonist remains first-line in some units, particularly for endometriosis, donor synchronisation, or after antagonist failure."^[13]