Reproductive Endocrinology and Infertility
What the exam tests
Anovulation, PCOS, endometriosis, male factor infertility, and assisted reproduction. Questions often ask for the first-line investigation or treatment.
Core rules
- PCOS (Rotterdam): two of oligo/anovulation, clinical or biochemical hyperandrogenism, and polycystic ovaries; exclude thyroid disease, hyperprolactinaemia, and congenital adrenal hyperplasia.
- First-line ovulation induction in PCOS is letrozole; clomiphene is an alternative. Metformin is adjunctive, especially with insulin resistance.
- Endometriosis: laparoscopy is diagnostic; treatment is hormonal suppression or surgery, but it does not reliably restore fertility.
- Male factor: semen analysis is the first test; repeat after 3 months if abnormal.
- IVF indications include tubal blockage, severe male factor, and failed ovulation induction. OHSS prevention uses antagonist protocols, low-dose gonadotropins, and freeze-all.
Worked example
A 29-year-old with 18 months of infertility has irregular cycles, BMI 32, and hirsutism. Her partner’s semen analysis is normal. Diagnosis: PCOS. First steps are lifestyle change, metformin if indicated, and letrozole with ovulation monitoring. If there is no pregnancy after 6 ovulatory cycles, refer for gonadotropins or IVF. The reasoning: letrozole has higher live-birth rates than clomiphene and avoids multiple pregnancy better than gonadotropins.
Traps
Diagnosing PCOS on ultrasound alone; ignoring the male partner; treating endometriosis with hormones to improve fertility; and missing thyroid dysfunction or hyperprolactinaemia.