Fertility-preserving surgical techniques US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Fertility-preserving surgical techniques. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Fertility-preserving surgical techniques US Medical PG Question 1: A 33-year-old woman comes to the emergency department because of a 1-hour history of severe pelvic pain and nausea. She was diagnosed with a follicular cyst in the left ovary 3 months ago. The cyst was found incidentally during a fertility evaluation. A pelvic ultrasound with Doppler flow shows an enlarged, edematous left ovary with no blood flow. Laparoscopic evaluation shows necrosis of the left ovary, and a left oophorectomy is performed. During the procedure, blunt dissection of the left infundibulopelvic ligament is performed. Which of the following structures is most at risk of injury during this step of the surgery?
- A. Bladder trigone
- B. Uterine artery
- C. Kidney
- D. Ureter (Correct Answer)
Fertility-preserving surgical techniques Explanation: ***Ureter***
- The **infundibulopelvic ligament** (also known as the suspensory ligament of the ovary) contains the **ovarian artery and vein** and is in close proximity to the ureter as it crosses the pelvic brim.
- During dissection or clamping of this ligament, especially in an emergency setting or when anatomy is distorted (e.g., by an enlarged ovary or edema), the **ureter** is highly susceptible to injury.
*Bladder trigone*
- The **bladder trigone** is the smooth triangular region at the base of the bladder, formed by the openings of the ureters and the internal urethral orifice.
- It is not directly adjacent to the infundibulopelvic ligament and is therefore at a comparably lower risk of injury during dissection of this ligament.
*Uterine artery*
- The **uterine artery** travels within the cardinal ligament and supplies the uterus; it is located more medially and inferiorly within the broad ligament.
- While important in pelvic surgery, it is not in the immediate vicinity of the infundibulopelvic ligament dissection itself.
*Kidney*
- The **kidneys** are retroperitoneal organs located much higher in the abdominal cavity, far superior to the pelvis.
- They are not at risk of direct injury during pelvic surgery involving the infundibulopelvic ligament.
Fertility-preserving surgical techniques US Medical PG Question 2: A 28-year-old woman comes to the physician because she has not had a menstrual period for 3 months. Menarche occurred at the age of 12 years and menses occurred at regular 30-day intervals until they became irregular 1 year ago. She is 160 cm (5 ft 3 in) tall and weighs 85 kg (187 lb); BMI is 33.2 kg/m2. Physical exam shows nodules and pustules along the jaw line and dark hair growth around the umbilicus. Pelvic examination shows a normal-sized, retroverted uterus. A urine pregnancy test is negative. Without treatment, this patient is at greatest risk for which of the following?
- A. Choriocarcinoma
- B. Mature cystic teratoma
- C. Endometrial carcinoma (Correct Answer)
- D. Endometrioma
- E. Cervical carcinoma
Fertility-preserving surgical techniques Explanation: ***Endometrial carcinoma***
- The patient's presentation including **amenorrhea**, **obesity** (BMI 33.2 kg/m²), **hirsutism** (dark hair around the umbilicus), and **acne** (nodules and pustules along the jawline) strongly suggests **Polycystic Ovary Syndrome (PCOS)**.
- In PCOS, chronic anovulation leads to unopposed **estrogen stimulation** of the endometrium, increasing the risk of **endometrial hyperplasia** and subsequently **endometrial carcinoma**.
*Choriocarcinoma*
- This is a rare, aggressive form of **gestational trophoblastic disease** that typically develops after a **hydatidiform mole** or pregnancy.
- The patient's negative pregnancy test and lack of prior abnormal pregnancy rule out this condition.
*Mature cystic teratoma*
- This is a common **benign ovarian tumor** that contains mature tissues from all three germ layers.
- It does not typically cause **amenorrhea** or symptoms of **hyperandrogenism** like those described.
*Endometrioma*
- This is a type of **endometriosis** where endometrial tissue grows on the ovaries, forming blood-filled "chocolate cysts."
- While it can cause pelvic pain and dysmenorrhea, it is not associated with **amenorrhea** or the **hyperandrogenic** features seen in this patient.
*Cervical carcinoma*
- This type of cancer is primarily caused by **Human Papillomavirus (HPV) infection** and is usually diagnosed through Pap smears.
- The patient's symptoms are not characteristic of cervical cancer, which typically presents with abnormal vaginal bleeding or postcoital bleeding.
Fertility-preserving surgical techniques US Medical PG Question 3: A 37-year-old G4P3 presents to her physician at 20 weeks gestation for routine prenatal care. Currently, she has no complaints; however, in the first trimester she was hospitalized due to acute pyelonephritis and was treated with cefuroxime. All her past pregnancies required cesarean deliveries for medical indications. Her history is also significant for amenorrhea after weight loss at 19 years of age and a cervical polypectomy at 30 years of age. Today, her vital signs are within normal limits and a physical examination is unremarkable. A transabdominal ultrasound shows a normally developing male fetus without morphologic abnormalities, anterior placement of the placenta in the lower uterine segment, loss of the retroplacental hypoechoic zone, and visible lacunae within the myometrium. Which of the following factors present in this patient is a risk factor for the condition she has developed?
- A. A history of amenorrhea
- B. Genitourinary infections during pregnancy
- C. Multiple cesarean deliveries (Correct Answer)
- D. Intake of antibiotics in the first trimester
- E. Cervical surgery
Fertility-preserving surgical techniques Explanation: ***Multiple cesarean deliveries***
- The ultrasound findings of an **anterior low-lying placenta**, **loss of the retroplacental hypoechoic zone**, and **visible lacunae within the myometrium** are classic signs of **placenta accreta spectrum (PAS)**.
- Previous uterine surgeries, particularly **cesarean deliveries**, are the most significant risk factor for PAS, as they can cause defects in the uterine wall that allow the placenta to abnormally implant.
*A history of amenorrhea*
- **Amenorrhea** after weight loss at a young age suggests a potential history of **hypothalamic amenorrhea** or other ovulatory dysfunction, which is not a direct risk factor for placenta accreta.
- This condition primarily affects **fertility** and menstrual regularity, not placental implantation depth.
*Genitourinary infections during pregnancy*
- While **pyelonephritis** in pregnancy is a serious condition, it is an **infection** and does not directly cause abnormal placental implantation or placenta accreta.
- Infections can lead to other complications like **preterm labor** or sepsis, but not PAS.
*Intake of antibiotics in the first trimester*
- **Antibiotic use** for treating infections like pyelonephritis does not contribute to the development of placenta accreta.
- Antibiotics are used to resolve bacterial infections and have no known mechanistic link to placental adherence disorders.
*Cervical surgery*
- **Cervical polypectomy** is a minor surgical procedure involving the cervix, not the uterine corpus.
- While other uterine surgeries (e.g., myomectomy) can be risk factors for PAS, a cervical polypectomy typically does not affect the myometrium or increase the risk of abnormal placental adherence.
Fertility-preserving surgical techniques US Medical PG Question 4: A 31-year-old female presents to her gynecologist with spotting between periods. She reports that her menses began at age 11, and she has never had spotting prior to the three months ago. Her medical history is significant for estrogen-receptor positive intraductal carcinoma of the breast, which was treated with tamoxifen. An endometrial biopsy is performed, which shows endometrial hyperplasia with atypia. She reports that she and her husband are currently trying to have children. What is the next best step?
- A. Start progestin-only therapy (Correct Answer)
- B. Partial, cervix-sparing hysterectomy
- C. Observation with annual endometrial biopsies
- D. Start combination estrogen and progestin therapy
- E. Total abdominal hysterectomy with bilateral salpingo-oophorectomy
Fertility-preserving surgical techniques Explanation: ***Start progestin-only therapy***
- This patient has **endometrial hyperplasia with atypia**, which carries a high risk of progression to **endometrial cancer**, especially when associated with **tamoxifen use**.
- Given her desire for **fertility preservation**, **high-dose progestin therapy** (e.g., megestrol acetate, medroxyprogesterone acetate) is the **first-line treatment** to reverse the hyperplasia while allowing for potential conception.
*Partial, cervix-sparing hysterectomy*
- This procedure treats the uterus but would still preclude future pregnancies and is typically reserved for cases where definitive surgical management is required but the patient wishes to preserve vaginal function.
- It would be too aggressive for a patient desiring fertility who has not failed medical therapy, and it does not remove the at-risk endometrium effectively.
*Observation with annual endometrial biopsies*
- **Endometrial hyperplasia with atypia** has a significant risk of progressing to **endometrial carcinoma**, estimated at 29% over 20 years.
- Simply observing without intervention is **inappropriate** given this high risk, even with regular monitoring.
*Start combination estrogen and progestin therapy*
- The patient's endometrial hyperplasia is likely due to the **unopposed estrogenic effect of tamoxifen** on the endometrium, which acts as a selective estrogen receptor modulator (SERM).
- Adding **estrogen** would exacerbate the problem and increase the risk of endometrial cancer, making this an unsafe and inappropriate treatment.
*Total abdominal hysterectomy with bilateral salpingo-oophorectomy*
- This is a definitive surgical treatment for endometrial hyperplasia with atypia and endometrial cancer, and would effectively remove the affected tissue.
- However, this option would render the patient **infertile**, which contradicts her expressed desire to have children. It would be considered if progestin therapy fails or if fertility is not a concern.
Fertility-preserving surgical techniques US Medical PG Question 5: A 28-year-old woman comes to the physician because she is unable to conceive for 3 years. She and her partner are sexually active and do not use contraception. They were partially assessed for this complaint 6 months ago. Analysis of her husband's semen has shown normal sperm counts and hormonal assays for both partners were normal. Her menses occur at regular 28-day intervals and last 5 to 6 days. Her last menstrual period was 2 weeks ago. She had a single episode of urinary tract infection 4 years ago and was treated with oral antibiotics. Vaginal examination shows no abnormalities. Bimanual examination shows a normal-sized uterus and no palpable adnexal masses. Rectal examination shows no abnormalities. Which of the following is the most appropriate next step in diagnosis?
- A. Postcoital testing
- B. Hysteroscopy
- C. Psychological counseling only
- D. Hysterosalpingogram (Correct Answer)
- E. Chromosomal karyotyping
Fertility-preserving surgical techniques Explanation: ***Hysterosalpingogram***
- A **hysterosalpingogram (HSG)** is the most appropriate next step to assess **fallopian tube patency** and uterine cavity abnormalities, which are common causes of infertility after male and ovulatory factors have been ruled out.
- The patient's history (3 years of infertility, normal male factors, regular menses suggesting ovulation) points to a need to investigate potential **tubal obstruction** or **uterine structural issues**.
*Postcoital testing*
- **Postcoital testing** evaluates sperm-mucus interaction and cervical factor infertility.
- While previously a common initial test, its **predictive value is low** and it is no longer routinely recommended as a primary diagnostic step in infertility workups.
*Hysteroscopy*
- **Hysteroscopy** is an invasive procedure that directly visualizes the uterine cavity.
- While it can identify **intrauterine pathologies** (e.g., polyps, fibroids, adhesions), it is generally performed *after* an HSG has suggested an abnormality or when initial workup points strongly to a uterine factor.
*Psychological counseling only*
- While infertility is a significant emotional stressor, **psychological counseling alone** is not a diagnostic step and does not address the underlying medical cause of infertility.
- Counseling can be offered as a supportive measure in conjunction with medical diagnostics and treatment.
*Chromosomal karyotyping*
- **Chromosomal karyotyping** is indicated in cases of **recurrent pregnancy loss**, severe male factor infertility (e.g., azoospermia), or suspected genetic syndromes.
- The patient's history does not suggest these indications, and her regular menses imply normal ovarian function, making genetic causes less likely as an initial diagnostic step.
Fertility-preserving surgical techniques US Medical PG Question 6: A 27-year-old female presents to her OB/GYN for a check-up. During her visit, a pelvic exam and Pap smear are performed. The patient does not have any past medical issues and has had routine gynecologic care with normal pap smears every 3 years since age 21. The results of the Pap smear demonstrate atypical squamous cells of undetermined significance (ASCUS). Which of the following is the next best step in the management of this patient?
- A. Repeat Pap smear in 1 year
- B. Perform colposcopy
- C. Perform an HPV DNA test (Correct Answer)
- D. Perform a Loop Electrosurgical Excision Procedure (LEEP)
- E. Repeat Pap smear in 3 years
Fertility-preserving surgical techniques Explanation: ***Perform an HPV DNA test***
- For women aged 25-29 with an **ASCUS Pap smear result**, the recommended next step is to perform an **HPV DNA test** to triage the finding.
- If the HPV test is positive, a colposcopy is indicated. If negative, routine screening can resume.
*Repeat Pap smear in 1 year*
- This approach is typically recommended for adolescents (age < 21) with an ASCUS result or for women aged 21-24 if HPV testing is not available.
- For women aged 25-29, **HPV testing** is preferred to determine the need for colposcopy.
*Perform colposcopy*
- **Colposcopy** is indicated if the HPV DNA test is positive following an ASCUS result in women 25-29, or for persistent ASCUS or low-grade squamous intraepithelial lesion (LSIL) results in younger women.
- It is not the immediate next step for ASCUS in this age group without prior HPV status.
*Perform a Loop Electrosurgical Excision Procedure (LEEP)*
- **LEEP** is a treatment for high-grade cervical dysplasia (HSIL) or recurrent/persistent LSIL, not a diagnostic step for initial ASCUS.
- Performing a LEEP based solely on an **ASCUS result** would be overly aggressive and may lead to unnecessary complications.
*Repeat Pap smear in 3 years*
- **Repeating a Pap smear in 3 years** is the recommendation for women with a normal Pap smear and negative HPV test, or for those who had an ASCUS/LSIL result with negative HPV testing and subsequent normal screening.
- It is not appropriate for an initial ASCUS finding in a 27-year-old.
Fertility-preserving surgical techniques US Medical PG Question 7: A 36-year-old African American G1P0010 presents to her gynecologist for an annual visit. She has a medical history of hypertension, for which she takes hydrochlorothiazide. The patient’s mother had breast cancer at age 68, and her sister has endometriosis. At this visit, the patient’s temperature is 98.6°F (37.0°C), blood pressure is 138/74 mmHg, pulse is 80/min, and respirations are 13/min. Her BMI is 32.4 kg/m^2. Pelvic exam reveals a nontender, 16-week sized uterus with an irregular contour. A transvaginal ultrasound is performed and demonstrates a submucosal leiomyoma. This patient is at most increased risk of which of the following complications?
- A. Endometrial cancer
- B. Miscarriage
- C. Infertility
- D. Uterine prolapse
- E. Iron deficiency anemia (Correct Answer)
Fertility-preserving surgical techniques Explanation: ***Iron deficiency anemia***
- Submucosal leiomyomas (fibroids) can cause significantly **heavy and prolonged menstrual bleeding**, known as menometrorrhagia, leading to chronic blood loss.
- This chronic blood loss depletes iron stores in the body, resulting in **iron deficiency anemia**.
*Endometrial cancer*
- While obesity is a risk factor for endometrial cancer, **leiomyomas themselves are not directly premalignant** or associated with an increased risk of endometrial carcinoma.
- The patient's irregular uterus is consistent with fibroids, not necessarily endometrial hyperplasia or cancer.
*Miscarriage*
- **Large or submucosal fibroids** can increase the risk of miscarriage by disrupting endometrial blood supply or distorting the uterine cavity.
- However, the most immediate and common complication of fibroids, particularly submucosal ones, is heavy bleeding leading to anemia.
*Infertility*
- Submucosal leiomyomas can interfere with **implantation** or **sperm transport**, thus contributing to infertility.
- However, for a G1P0010 patient, the most *likely* immediate complication associated with significant bleeding from a submucosal fibroid is anemia, before issues with future conception are explicitly addressed.
*Uterine prolapse*
- Uterine prolapse is typically due to **weakening of pelvic floor support structures**, often associated with parity, age, and conditions increasing intra-abdominal pressure.
- While a large uterus from fibroids could theoretically contribute, it is not the primary or most common complication of fibroids; heavy bleeding is much more direct and frequent.
Fertility-preserving surgical techniques US Medical PG Question 8: A 38-year-old woman presents to her primary care physician concerned about her inability to get pregnant for the past year. She has regular menstrual cycles and has unprotected intercourse with her husband daily. She is an immigrant from Australia and her past medical history is not known. She is currently taking folic acid and multivitamins. The patient's husband has had a sperm count that was determined to be within the normal range twice. She is very concerned about her lack of pregnancy and that she is too old. Which of the following is the most appropriate next step in management for this patient?
- A. Repeat semen count
- B. Assess ovulation with an ovulation calendar
- C. Perform hysterosalpingogram (Correct Answer)
- D. Advise against pregnancy given the patient's age
- E. Continue regular intercourse for 1 year
Fertility-preserving surgical techniques Explanation: ***Perform hysterosalpingogram***
- Given the patient’s age and duration of infertility (1 year at age 38, typically evaluation starts earlier for those over 35), assessing **tubal patency** with a **hysterosalpingogram (HSG)** is an essential step in the infertility workup.
- HSG can identify structural abnormalities like **blocked fallopian tubes** or **uterine anomalies**, which are common causes of infertility.
*Repeat semen count*
- The husband has already had **two normal semen analyses**, making further repeated testing at this stage less likely to yield new information or be the most appropriate next step.
- While male factor infertility is common, it has been reasonably excluded here, shifting the focus to female factors.
*Assess ovulation with an ovulation calendar*
- The patient reports having **regular menstrual cycles**, which strongly suggests she is **ovulating regularly**.
- Ovulation calendars are often used to identify the fertile window but are less useful for confirming ovulation in someone with regular cycles when investigating infertility causes.
*Advise against pregnancy given the patient's age*
- While **fertility declines with age**, advising against pregnancy is inappropriate and **premature** without a proper infertility workup.
- Many women in their late 30s and early 40s successfully conceive with appropriate management and intervention.
*Continue regular intercourse for 1 year*
- For women aged 35 or older, an infertility evaluation is typically initiated after **6 months of unprotected intercourse** without conception.
- The patient is 38 and has been trying for a year, so further delay is not recommended; an immediate workup is warranted.
Fertility-preserving surgical techniques US Medical PG Question 9: A 32-year-old man is brought to the emergency department after a skiing accident. The patient had been skiing down the mountain when he collided with another skier who had stopped suddenly in front of him. He is alert but complaining of pain in his chest and abdomen. He has a past medical history of intravenous drug use and peptic ulcer disease. He is a current smoker. His temperature is 97.4°F (36.3°C), blood pressure is 77/53 mmHg, pulse is 127/min, and respirations are 13/min. He has a GCS of 15 and bilateral shallow breath sounds. His abdomen is soft and distended with bruising over the epigastrium. He is moving all four extremities and has scattered lacerations on his face. His skin is cool and delayed capillary refill is present. Two large-bore IVs are placed in his antecubital fossa, and he is given 2L of normal saline. His FAST exam reveals fluid in Morison's pouch. Following the 2L normal saline, his temperature is 97.5°F (36.4°C), blood pressure is 97/62 mmHg, pulse is 115/min, and respirations are 12/min.
Which of the following is the best next step in management?
- A. Diagnostic peritoneal lavage
- B. Emergency laparotomy (Correct Answer)
- C. Upper gastrointestinal endoscopy
- D. Close observation
- E. Diagnostic laparoscopy
Fertility-preserving surgical techniques Explanation: ***Emergency laparotomy***
- The patient remains **hemodynamically unstable** (BP 97/62 mmHg, HR 115/min after 2L IV fluids) with evidence of **intra-abdominal fluid on FAST exam** (fluid in Morison's pouch).
- This clinical picture indicates active intra-abdominal hemorrhage requiring **immediate surgical intervention** to identify and control the source of bleeding.
*Diagnostic peritoneal lavage*
- **Diagnostic peritoneal lavage (DPL)** has largely been replaced by the focused abdominal sonography for trauma (FAST) exam and CT scans.
- While it can detect intra-abdominal bleeding, it is **invasive** and would delay definitive treatment in a hemodynamically unstable patient with positive FAST.
*Upper gastrointestinal endoscopy*
- This procedure is primarily for diagnosing and treating **upper gastrointestinal bleeding** or mucosal abnormalities.
- It is **not indicated** for evaluating traumatic intra-abdominal hemorrhage or hemodynamic instability following blunt abdominal trauma.
*Close observation*
- Close observation is appropriate for **hemodynamically stable patients** with blunt abdominal trauma and minor injuries or equivocal findings.
- This patient's persistent hypotension, tachycardia, and positive FAST findings rule out observation as a safe or appropriate next step.
*Diagnostic laparoscopy*
- **Diagnostic laparoscopy** is a minimally invasive surgical procedure used to evaluate the abdominal cavity.
- While it can be diagnostic, it is generally **contraindicated in hemodynamically unstable patients** as it can prolong the time to definitive hemorrhage control if a major injury is found.
Fertility-preserving surgical techniques US Medical PG Question 10: A 39-year-old man presents with painless swelling of the right testis and a sensation of heaviness. The physical examination revealed an intra-testicular solid mass that could not be felt separately from the testis. After a thorough evaluation, he was diagnosed with testicular seminoma. Which of the following group of lymph nodes are most likely involved?
- A. Superficial inguinal lymph nodes (lateral group)
- B. Deep inguinal lymph nodes
- C. Superficial inguinal lymph nodes (medial group)
- D. Para-rectal lymph nodes
- E. Para-aortic lymph nodes (Correct Answer)
Fertility-preserving surgical techniques Explanation: ***Para-aortic lymph nodes***
- The **testes** develop in the abdomen and descend into the scrotum, retaining their original lymphatic drainage. Therefore, **testicular cancer** typically metastasizes to the **para-aortic** (or retroperitoneal) lymph nodes, which are located near the renal veins at the level of L1-L2.
- This is the primary lymphatic drainage pathway for the testes.
*Superficial inguinal lymph nodes (lateral group)*
- These lymph nodes primarily drain the skin of the **scrotum**, perineum, and lower limbs, but not the **testes** themselves.
- Involvement would suggest spread to the scrotal skin or compromised lymphatic flow due to prior scrotal surgery or infection, which is not indicated here.
*Deep inguinal lymph nodes*
- **Deep inguinal lymph nodes** drain structures deeper in the leg and gluteal region, as well as receiving efferent vessels from the superficial inguinal nodes.
- They are not the primary drainage site for the **testes**.
*Superficial inguinal lymph nodes (medial group)*
- Similar to the lateral group, the **medial superficial inguinal lymph nodes** primarily drain the external genitalia (excluding the testes), perineum, and lower abdominal wall.
- They are not the direct drainage route for **testicular cancer**.
*Para-rectal lymph nodes*
- **Para-rectal lymph nodes** are located near the rectum and are involved in the drainage of the rectum and lower sigmoid colon.
- They have no direct connection to the lymphatic drainage of the **testes**.
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