Knowledge Area 11 | Subfertility

Knowledge Area 11 | Subfertility

(Aligned with RCOG Core Curriculum 2019)

• Subfertility is a clinically rich and conceptually integrated module. It requires Sound understanding of reproductive physiology; Structured investigation pathways; Evidence-based management; Holistic couple-centred counselling; Awareness of ethical and legal frameworks.
• The curriculum now places strong emphasis on multidisciplinary care, genetics, fertility preservation, and inclusive reproductive services.

What the RCOG Curriculum Expects

According to the RCOG Core Curriculum (2019, updated 2021), trainees must demonstrate competence in:

• Assessment of infertile couples
• Interpretation of ovarian reserve testing
• Management of ovulatory dysfunction
• Tubal and uterine factor evaluation
• Male factor infertility
• Assisted reproductive techniques (basic principles)
• Fertility preservation
• Counselling and psychological support
• Legal aspects including gamete donation and surrogacy

There is increasing emphasis on:

• Individualised fertility care
• Reproductive endocrinology
• Evidence-based use of ART
• Safety (OHSS prevention, multiple pregnancy reduction)
• Genomics and preimplantation testing
• NHS funding pathways and referral systems

How to Organise Your Study

Create a master folder:  Subfertility

Subfolders:

• Female Factors
• Male Factors
• Unexplained Subfertility
• Assisted Reproductive Techniques (ART)
• Fertility Preservation
• Ethical & Legal Issues

• For each condition, structure your notes under: Pathophysiology; Clinical features; First-line investigations; Interpretation of tests; Management options; Referral thresholds; Counselling points
• Consistency in note structure improves helps in solving exam questions..

Female Subfertility

Ovulatory Dysfunction (PCOS & Others)

• You must know WHO classification of anovulation; Rotterdam diagnostic criteria for PCOS; Metabolic implications; Ovulation induction protocols; Letrozole vs clomifene; Role of metformin; Monitoring for multiple pregnancy
• Letrozole is now first-line for ovulation induction in PCOS (per NICE NG156).

Endocrine Causes

• Understand Thyroid dysfunction; Hyperprolactinaemia; Hypothalamic amenorrhoea; Premature ovarian insufficiency
• Know investigation thresholds and referral to endocrinology where appropriate.

Endometriosis

• You must understand Impact on fertility; Role of surgery; When to proceed to IVF; Ovarian reserve implications after cystectomy

Tubal & Uterine Factors

• Know HSG vs HyCoSy vs laparoscopy; Congenital uterine anomalies; Absolute uterine factor infertility; Role of hysteroscopy; When ART is preferred over surgery

Male Subfertility (Often Underestimated)

• Curriculum now emphasises equal evaluation of male partner.
• Know: Semen analysis interpretation (WHO reference ranges); Azoospermia (obstructive vs non-obstructive); Varicocele; Genetic causes; When to refer to andrology
• Male factor accounts for ~40–50% of infertility cases — do not neglect this in exams.

Unexplained Subfertility

• You must understand Definition after normal investigations; Prognosis; Expectant management timelines; Role of IUI; When to escalate to IVF
• Avoid over-investigation — evidence-based pathways are key.

Assisted Reproductive Techniques (ART)

• At ST5 level in MRCOG exams, you are expected to understand principles, not perform procedures.
• Know IVF vs ICSI; Indications; Ovarian stimulation protocols; Risk of OHSS; Prevention strategies; Single embryo transfer policy; Perinatal risks
• Newer emphasis includes: Elective egg freezing; Preimplantation genetic testing; Frozen embryo transfer; Mild stimulation protocols

Fertility Preservation (Increasingly Tested)

• Understand Oocyte cryopreservation; Embryo freezing; Ovarian tissue freezing; Indications (oncology, Turner syndrome, premature ovarian insufficiency risk); Counselling limitations

Ethical & Legal Issues

• You must understand Surrogacy laws in the UK; Gamete donation regulations; Same-sex parenthood; Single parent IVF; The Human Fertilisation and Embryology Authority framework; Consent and storage limits; Embryo ownership disputes
• Be aware of NHS funding variability by region.

Exam now focuses on

• Letrozole as first-line ovulation induction
• Greater emphasis on ovarian reserve testing (AMH interpretation)
• More cautious approach to endometrioma surgery
• Increased attention to male infertility
• Wider availability of egg freezing
• Expanded legal storage periods for gametes
• Focus on reducing multiple pregnancy rates

Revision Strategy Before exam

• Memorise WHO semen reference ranges
• Revise ovulation induction protocols
• Understand AMH limitations
• Know IVF referral criteria
• Revise OHSS prevention
• Be confident in ethical scenarios

Final Word

• Subfertility is Physiology-heavy; Investigation-focused; Ethically nuanced; Frequently integrated with oncology and endocrine modules
• Approach it: Couple-centred; Stepwise; Evidence-based.;Legally aware
• If structured properly, this knowledge area becomes logical and highly scoring.

All the reading material, along with comprehensive summaries are provided in our courses.