Tuesday, April 16, 2024

TOG Topics List

This post is about the TOG topics list with links starting from 2012 till April 2024. The download links to the 'free access' articles have been provided. All you have to do is to click the specific topic and the article will be open in a new window.

My purpose in sharing it with you all is to give an idea about 'organising your study material' in a way to save your precious time. This is a practical answer to a  frequently asked question, “What are the TOG articles in a specific year?”

You need a subscription to access the articles for which no links are given. After a specific time, the article becomes free to access. The list will make sure that you get all the important articles. You must add to this list whenever a new TOG issue is published.

All the best.

Dr Rubab Khalid



APRIL 2024




APRIL 2023



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    Wednesday, April 03, 2024

    Endometriosis & Subfertility

    This blog post is based on points taken from a TOG article which was published in January 2024. This article delves into the pathology, diagnostic approaches, and management strategies for endometriosis-associated subfertility.

    To download the original article: Click Here

    To access ALL TOGs: Click Here


    • Prevalence of endometriosis in UK ~10% in reproductive age
    • With subfertility 25-50%
    • Clinical presentation pelvic pain, subfertility & bowel dysfunction or incidental (during fertility investigations)
    • Challenging to manage in context of subfertility as mainstays of management are often long-term hormonal treatments

    Pathology of endometriosis-associated infertility

    • Endometriosis defined as endometrial tissue, ectopic glands & stroma outside uterus, mostly within pelvis

    Anatomical distortion

    • Up to 30% women with endometriosis have tubal pathology. Tubal damage may impair egg capture & transport
    • Degree of endometriosis corresponds to decline in conception rates. Lower fertility rates even with mild disease


    • Found in 17-44% 1/3 have bilateral cysts
    • Detrimental to ovarian function. Can be a significant cause of dyspareunia
    • Recurrence 30% in 2-5 yrs after surgery 80% in treated ovary, 8% in both & 11% in contralateral ovary
    • Endometrioma presence is the marker of more severe disease
    • 50% with deep endometriosis (DE) have endometrioma

    Ref: TOG

    Investigating endometriosis-related subfertility

    • Must have a holistic diagnostic workup for subfertility
    • Baseline Ultrasound (USS), Ovarian reserve assessment (AMH & AFC), Ovulatory disorders, Tubal patency & Semen analysis
    • ESHRE guideline 
    • Laparoscopy no longer the gold standard for diagnosis of endometriosis 
    • Laparoscopy to be only done if negative imaging ± failed or inappropriate empirical t/m
    • Imaging to be done — MRI & USS as first-line for deep endometriosis. Choose an imaging depends on clinical skills & equipment availability

    Staging and scoring endometriosis

    revised American Society of Reproductive Medicine (rARSM) 

    • Originally designed to classify disease extent & relationship with pregnancy rate 
    • Most common & easy to use. Does not correlate with pain or subfertility

    ENZIAN scoring system

    • Descriptive surgical scoring system Applied to peri-operative imaging assessment
    • Proven clue in per-operative prediction of laparoscopic operating time
    • There is no or very little correlation with patient symptoms & infertility

    Endometriosis fertility index (EFI)

    • Specific for women where fertility is priority
    • 10-point scoring with 5 categories of risk
    • Developed to predict pregnancy rates in women with surgically assessed endometriosis attempting non-IVF conception
    • High inter-user reproducibility & good at predicting non-IVF pregnancy rates post-surgery & also pregnancy after ART
    • EFI can help in shared decision-making about whether to perform surgery

    Ref: TOG

    Management of endometriosis-related subfertility

    • Challenging to balance adequate management of symptoms & desire for fertility 
    • MDT approach — gynaecologist, colorectal surgeon, urologist, specialist nurses & fertility specialist 
    Ref: TOG

    Assisted conception in the context of endometriosis

    • Assisted conception offered as first-line t/m as best chance to achieve parenthood

    Effect of endometriosis on ART

      • minimal/mild no impact on clinical pregnancy or live birth rates
      • moderate/severe significantly lowers number of eggs collected & reduces live birth rate by ~1/4
      • Reduced number of retrieved oocytes but no effect on clinical pregnancy & live birth rates 

    Surgical treatment of endometriosis prior to ART

    • Surgical t/m of endometrioma prior to ART — does not improve live birth rate
    • Cystectomy
      • associated with poorer response to stimulation & greater risk of cycle cancellation as compared to no surgery 
      • reduces the risk of recurrence
    • Sclerotherapy vs Cystectomy — more oocytes collected & improved live birth rates with sclerotherapy
    • Routine removal of endometrioma prior to ART not recommended but considered if pain or to allow access to follicles at egg collection and in DE

    Risks of ART in women with endometriosis

    • IVF does not increase endometriosis-related pain, nor does IVF increase the risk of recurrence
    • Ovarian stimulation has minimal impact of endometrioma size
    • Risk of pelvic infection with an endometrioma undergoing egg collection <1% Use antibiotics (good practice)

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    Wednesday, October 04, 2023

    Tuberculosis in Pregnancy

    This is a quick summary of the points taken from the TOG article which was published in July 2023. It is an important exam topic so must be covered thoroughly.

    To download the original article: Click Here

    To Access All TOGs: Click Here

    To Join RK4 MRCOG Courses: Click Here


    • Tuberculosis (TB) is one of the leading infectious causes of overall mortality
    • Highest disease burden in low-resource countries 
    • >2/3 cases in Africa and Southeast Asia
    • Co-infection of TB & HIV in reproductive years is significant
    • In UK — increasing due to immigration 
    • Can have adverse effects on mother & fetus


    • Global incidence - 1990-2020 — 9.9 million with 1.3 million deaths worldwide 
    • Major contributors to the resurging global TB epidemic — Poverty, HIV Coinfection, Drug resistance
    • In 2020 UK had 4700 cases = 6.9 per 100 000
    • Risk of new migrant women having active TB highest in first 5 years of migration
    • Exact worldwide TB prevalence in pregnancy - Uncertain & depends on area
      • Low-prevalence countries 0.06-0.25%
      • High-prevalence countries 
        • 0.07-0.5% (in HIV negative)
        • 0.7-11% (in HIV-positive) 


    • Causative organism — Mycobacterium tuberculosis (non-spore-forming, aerobic & non-motile bacteria)
    • Primarily airborne infection
    • Can also occur through ingestion of unpasteurised milk or direct implantation
    • TB particles range from 1-5 microns in size, carried to terminal alveoli and multiply there
    • Alveolar macrophages ingest & destroy most of the particles, but few survive and continue to multiply
    • A granuloma is formed by macrophages around the bacilli
    • Usually, the immune system clears the infection, but if it fails, it remains dormant without clinical manifestations or may cause symptoms.
      • ~10% immunocompromised with latent TB will develop reactivation of TB
      • ~10% healthy acquire infection during their life
    • Most common form of clinical TB — Pulmonary disease
      • 20% active TB can present as extrapulmonary TB with cervical nodes being most common site (31%). 
      • Other sites are CNS, spinal cord, abdomen, pericardium (more common in immunocompromised & HIV-positive)
    Outcomes of primary TB infection 
    1. Latent TB
    2. Primary TB (within 2 years)
    3. Secondary TB

    Clinical Presentation 

    • Suspect TB if h/o exposure to patients with chronic cough or recent visits to endemic areas
    • Symptoms except for Fever same as non-pregnant — weight loss, night sweats, chills, appetite loss, tiredness & weakness
    • Latent disease will be asymptomatic & non-infectious but can have reactivation
    • Four-symptom screening for TB suggested by WHO 
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