Pelvic-factor infertility — structured oral station (12 minutes)

Opening prompt — "How would you approach the pelvic-factor assessment in this couple?"

Model response — say it in this order: ^[1][3]

• "I would confirm the structured couple workup is complete — semen analysis normal, ovulation confirmed, ovarian reserve adequate, and now pelvic-factor assessment. With no red flags for severe pelvic disease and no symptoms beyond mild dysmenorrhoea, I would order HyCoSy first-line as per NICE NG257 (2026) — outpatient transvaginal ultrasound with contrast, sensitivity ~93%, no radiation."^[1][3]
• "I would also screen for chlamydia and gonorrhoea BEFORE the HyCoSy — re-activation of subclinical PID can compromise the very tubes being assessed. Positive result requires treatment of the woman and the partner with abstinence until treatment complete."^[1]
• "Cavity assessment in the same visit — 3D transvaginal ultrasound or saline-infusion sonography for the fibroid."^[3]

Examiner is listening for: NICE NG257 ordering, the chlamydia screen as a prerequisite, and parallel assessment of the cavity. ^[1]

Probe 1 — "HyCoSy confirms the left hydrosalpinx and shows a normal right tube. What next?"

• "The left tube is hydrosalpinx; the right tube is patent. NICE NG257 (2026) gives endometriosis its own pathway and the hydrosalpinx needs to be addressed before IVF — the embryotoxic fluid halves the live birth rate."^[4]
• "I would offer salpingectomy of the left tube (or proximal tubal occlusion if the surgical risk is high) before IVF. The Cochrane review (Johnson 2010) confirms the benefit on pregnancy and live birth rates. The Turok 2021 study confirms salpingectomy and proximal occlusion are both effective."^[4][2]
• "Counselling — the loss of the tube for natural conception is irreversible. The right tube is patent so natural conception remains possible but unlikely given the hydrosalpinx and the FIGO 1 fibroid."

Probe 2 — "The 1.5-cm FIGO 1 submucosal fibroid — do you remove it?"

• "Yes — submucosal fibroids (FIGO 0-2) that distort the cavity reduce IVF pregnancy and live birth rates. The Cochrane review (Metwally 2015) supports hysteroscopic resection before IVF."^[11]
• "I would do this at the time of the salpingectomy or as a separate procedure before IVF. The cavity matters more than the myometrium."^[11]
• "For an intramural fibroid without cavity distortion, the evidence is more equivocal — the decision is individualised."

Probe 3 — "She asks about the surgery-versus-IVF debate for stage I-II endometriosis — what does the evidence say?"

• "Stage I-II endometriosis with infertility: NICE NG257 (2026) gives endometriosis its own dedicated pathway. ESHRE- and ASRM-endorsed options are EITHER laparoscopic surgery (excision or ablation) OR direct ART — both are valid. The choice is patient-driven after counselling on age, prior treatment, partner semen, and symptoms."^[1][5]
• "The Cochrane review (Jacobson 2010) supports laparoscopic surgery for stage I-II endometriosis compared with diagnostic laparoscopy alone — improves pregnancy rates. But direct ART also works, and the surgery-or-IVF debate is informed by the patient preference, the symptom burden, and the cost/availability of surgery."^[5]
• "Do NOT use medical therapy (GnRH analogues, COC, progestins) as a fertility treatment — these are contraceptive."

Probe 4 — "What if she had a 4-cm ovarian endometrioma instead — would you remove it?"

• "Each cystectomy reduces AMH — healthy ovarian cortex is removed with the cyst wall, and the bipolar diathermy or suture haemostasis further compromises the ovarian reserve. The 'three-strike' rule applies — the third cystectomy is rarely in the patient's interest."^[2]
• "For women over 35 or with low ovarian reserve, consider ART with the cyst in situ to preserve ovarian function. For younger women with a large cyst, cystectomy may improve spontaneous pregnancy but at the cost of some ovarian reserve."
• "Decision is individualised with the patient — discuss the trade-off and offer both pathways."

Probe 5 — "She asks about the IVF success rate and the role of the partner."

• "For a 33-year-old with normal ovarian reserve and her partner with normal semen, IVF live birth rate per fresh embryo transfer is around 30 to 40% per cycle. The age on the chart is the most important determinant of ART success — at 33, success rates are favourable." ^[1]
• "The couple needs to know that pre-IVF optimisation matters — salpingectomy for the hydrosalpinx, hysteroscopic myomectomy for the FIGO 1 fibroid, and lifestyle measures (BMI, smoking, alcohol) all contribute."
• "Psychosocial support is part of the package — infertility distress, anxiety and depression are common and treatable. NICE NG257 (2026) requires inclusive counselling."