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Subfertility with previous pelvic inflammatory disease — DFSRH MCQ

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EasyFertilitySubfertility with previous pelvic inflammatory diseaseDFSRH

A 33-year-old woman and her 35-year-old male partner are referred after 14 months of regular unprotected vaginal intercourse without conception. She has predictable 28-day menstrual cycles and no galactorrhoea, thyroid symptoms, abnormal uterine bleeding or current pelvic pain. Five years ago, she required hospital treatment for pelvic inflammatory disease. A recent chlamydia nucleic acid amplification test is negative. Her partner has no relevant medical history, and neither partner has previously undergone fertility investigations. Which initial specialist investigation plan is most appropriate?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: E — Semen analysis; mid-luteal serum progesterone; laparoscopy and dye

Explanation lettering: B = shown as A · A = shown as B · E = shown as C · C = shown as D · D = shown as E

Both partners require assessment because failure to conceive has persisted beyond 12 months. The male partner should undergo semen analysis. Although regular monthly cycles make ovulation likely, NICE recommends mid-luteal serum progesterone to confirm ovulation during infertility investigations, including in women with regular cycles. The decisive discriminator is her previous pelvic inflammatory disease, which raises the likelihood of tubal and other pelvic pathology. NICE recommends laparoscopy and dye when such a comorbidity is present because it can assess tubal patency and inspect the pelvis concurrently. Therefore, D is the best answer. A is incorrect because gonadotrophins are principally indicated when cycles are irregular, and HSG is not the preferred tubal assessment in this higher-risk context. B is a strong near-miss: HSG is less invasive and appropriate when there is no relevant tubal or pelvic comorbidity, but previous PID favours laparoscopy and dye. C is incorrect because AMH predicts ovarian response during assisted conception rather than the probability of spontaneous conception; HyCoSy is also intended primarily for patients without relevant comorbidity. E is incorrect because hysteroscopy is not indicated without clinical suspicion of uterine or endometrial abnormality and does not provide the required comprehensive assessment of tubal and pelvic pathology.

Reference: Fertility problems: assessment and treatment — Investigation of fertility problems and management strategies (31 March 2026) — https://www.nice.org.uk/guidance/ng257/chapter/Investigation-of-fertility-problems-and-management-strategies NG257 visual summaries on conception and assessment of fertility problems (March 2026) — https://www.nice.org.uk/guidance/ng257/resources/visual-summaries-on-conception-by-vaginal-sexual-intercourse-or-artificial-insemination-and-pdf-15664333357