Fertility and Infertility Practice Questions

Q: Which of the following statements about hysterosalpingography, as a diagnostic procedure, are correct? I. Tubal patency assessment following tuboplasty operation II. Diagnosis of uterine synechiae III. Detection of IUD IV. Diagnosis of subserosal fibroid Select the answer using the code given below :

I, II and III. ***I, II and III*** Hysterosalpingography (HSG) is a radiological procedure that uses contrast material injected into the uterus to visualize the **uterine cavity** and **fallopian tubes** under fluoroscopy. It is specifically useful for: **Statement I - Tubal patency assessment following tuboplasty operation** ✓ - HSG is the standard procedure to evaluate whether fallopian tubes remain patent after reconstructive tubal surgery **Statement II - Diagnosis of uterine synechiae** ✓ - HSG excellently demonstrates intrauterine adhesions (Asherman's syndrome) as filling defects in the uterine cavity **Statement III - Detection of IUD** ✓ - Radiopaque IUDs are easily visualized on HSG, and the procedure can confirm proper IUD position within the uterine cavity **Statement IV - Diagnosis of subserosal fibroid** ✗ - **Subserosal fibroids** project outward from the uterine serosa into the peritoneal cavity - HSG only outlines the **endometrial cavity** and **tubal lumen**, not external uterine surfaces - These fibroids do not impinge on the uterine cavity and therefore cannot be visualized by HSG - Better diagnosed by **ultrasound** or **MRI** *I, II and IV* - While HSG is excellent for assessing tubal patency and diagnosing uterine synechiae (I and II), it cannot diagnose **subserosal fibroids** which are located on the outer surface of the uterus and do not affect the uterine cavity outline. *II, III and IV* - This option correctly identifies HSG's utility in diagnosing **uterine synechiae** and detecting **IUDs**, but incorrectly includes **subserosal fibroids** which cannot be visualized by this procedure. *I, III and IV* - This option accurately includes HSG's role in assessing **tubal patency** and detecting **IUDs**, but mistakenly includes diagnosis of **subserosal fibroids** which require imaging modalities that visualize the external uterine surface.

Q: A 27-year-old female married for 3 years regularly cohabiting with husband presents to Gynaecology OPD with complaints of inability to conceive for 2 years. During clinical evaluation hysterosalpingography was done which revealed irregular outline of uterine cavity and rigid fallopian tubes with nodulations. Most likely cause for this condition is :

Genital Tuberculosis. ***Genital Tuberculosis*** - The combination of **infertility**, an **irregular uterine cavity outline**, and **rigid fallopian tubes with nodulations** on hysterosalpingography (HSG) is highly suggestive of genital tuberculosis. - **Tuberculosis** can cause significant scarring and obstruction in the female reproductive tract, leading to these characteristic HSG findings and impaired fertility. *Syphilis* - While syphilis is a sexually transmitted infection, it typically causes **chancre formation**, **rash**, and systemic symptoms; it does not typically lead to the described HSG findings of an irregular uterine cavity or rigid, nodulated fallopian tubes. - Infertility can be a consequence of untreated syphilis (e.g., through miscarriage), but the specific morphological changes seen in the uterus and tubes are not characteristic of this infection. *Genital Herpes* - Genital herpes is caused by the herpes simplex virus and is characterized by recurrent outbreaks of **painful blisters and ulcers** in the genital area. - It does not cause structural changes to the uterus or fallopian tubes that would result in an irregular uterine outline or rigid, nodulated tubes as seen on HSG. *Gonorrhoea* - Gonorrhoea can cause **pelvic inflammatory disease (PID)**, which can lead to tubal damage and infertility; however, the typical HSG findings are often **hydrosalpinx** or extensive peritubal adhesions, rather than rigid, nodulated tubes with an irregular uterine outline. - While it can result in tubal obstruction, the specific pattern described in the question (irregular uterine outline, rigid tubes with nodulations) is more characteristic of the chronic inflammatory and fibrotic changes associated with tuberculosis.

Q: Which of the following days of menstrual cycle is best for endometrial sampling to diagnose ovulation?

21st - 23rd day. ***21st - 23rd day*** - This period corresponds to the **mid-secretory phase** (~7 days post-ovulation), when **progesterone-induced secretory changes** are fully established and most reliable for histological confirmation of ovulation. - The endometrium shows **mature secretory features** including prominent subnuclear vacuoles, stromal edema, and spiral artery development, making it the **textbook recommendation** for endometrial dating. *12th - 14th day* - This represents the **late proliferative phase** or **periovulatory period**, when ovulation is occurring but secretory changes have not yet developed. - Endometrial histology would show **proliferative features** with straight tubular glands and mitotic activity, lacking the progesterone effect needed to diagnose ovulation. *16th - 20th day* - This period falls in the **early secretory phase**, showing only **initial secretory changes** that may be incomplete or unreliable for definitive diagnosis. - While some progesterone effect may be present, the changes are **not fully mature** compared to the optimal 21st-23rd day window recommended in standard gynecology texts. *8th - 10th day* - This corresponds to the **early proliferative phase**, well before ovulation occurs, when estrogen dominates and no secretory changes are present. - Endometrial sampling would show **proliferative endometrium** with no evidence of progesterone effect, making it unsuitable for diagnosing ovulation.

Q: Which of the following are factors for poor outcome following tuboplasty? 1. Dense pelvic adhesions 2. Length of reconstructed tube less than 4 cm 3. Bilateral hydrosalpinx 4. Reversal after 5 years of sterilization procedure Select the correct answer using the code given below.

1, 2 and 3. ***1, 2 and 3*** - **Dense pelvic adhesions** impair tubal motility and increase the risk of ectopic pregnancy, leading to poor outcomes after tuboplasty. - A **reconstructed tube length less than 4 cm** significantly reduces the available surface area for fertilization and embryo transport, negatively impacting fertility success rates. - **Bilateral hydrosalpinx** indicates severe tubal damage with impaired ciliary function and potentially toxic fluid accumulation, which drastically reduces the chances of successful pregnancy even after surgical repair. *1, 2 and 4* - This option incorrectly includes "Reversal after 5 years of sterilization procedure" while omitting bilateral hydrosalpinx, which is a more significant poor prognostic factor. - While duration since sterilization can influence outcomes, anatomical factors like hydrosalpinx are more critical predictors of tuboplasty failure. *2, 3 and 4* - This option incorrectly omits "Dense pelvic adhesions," which is one of the most important poor prognostic factors in tuboplasty. - Severe pelvic adhesions directly compromise tubal function and significantly increase ectopic pregnancy risk. *1, 3 and 4* - This option incorrectly omits "Length of reconstructed tube less than 4 cm," which is a critical anatomical factor directly influencing tuboplasty success. - Adequate tubal length is essential for proper gamete transport and fertilization; tubes shorter than 4 cm have significantly reduced success rates.

Q: What is the most common first-line investigation used to assess the patency of fallopian tubes?

Hysterosalpingogram. ***Hysterosalpingogram (HSG)*** - **Hysterosalpingogram (HSG)** is the **most common first-line investigation** for assessing tubal patency in infertility workup. - It involves injecting a radio-opaque contrast dye through the cervix into the uterine cavity and fallopian tubes, followed by X-ray imaging. - HSG effectively visualizes the **uterine cavity anatomy** and **tubal patency**, detecting blockages or abnormalities. - It is **minimally invasive, outpatient-based**, and provides both diagnostic and potentially therapeutic benefit (flushing effect). *Sonohysterogram* - **Sonohysterogram (SIS)** primarily evaluates the **uterine cavity** for intrauterine pathology like polyps, fibroids, or septae using saline infusion and ultrasound. - A modified version (**HyCoSy** - hystero-salpingo-contrast sonography) can assess tubal patency but is **less commonly used** than HSG as a first-line test. - Standard sonohysterogram does not directly visualize tubal patency. *Laparoscopic chromopertubation* - **Laparoscopic chromopertubation** is the **gold standard invasive method** for directly visualizing tubal patency. - A colored dye (methylene blue) is injected through the cervix and observed flowing through the fimbriated ends of the tubes under direct laparoscopic visualization. - It is **reserved for cases** where non-invasive tests are inconclusive or when concurrent treatment of pelvic pathology (adhesions, endometriosis) is planned. - It is **not a first-line test** due to its invasive nature, cost, and need for anesthesia. *CT scan* - **CT scan** is not used for assessing fallopian tube patency. - While it provides excellent anatomical detail of pelvic organs, it cannot effectively demonstrate the patency or flow through the narrow fallopian tube lumen. - CT is useful for evaluating pelvic masses, malignancies, or complications but not for functional tubal assessment.

Q: Which of the following is the marker of ovarian reserve?

Anti-Mullerian hormone. ***Anti-Mullerian hormone*** - **Anti-Mullerian hormone (AMH)** is produced by the granulosa cells of small antral and pre-antral follicles in the ovary. - AMH levels correlate with the size of the **primordial follicle pool**, making it the **most reliable indicator of ovarian reserve**. - Unlike other markers, AMH remains relatively **constant throughout the menstrual cycle** and can be measured on any day. - AMH is the **preferred marker** in fertility assessment and IVF planning. *β-hCG* - **Beta-human chorionic gonadotropin (β-hCG)** is a hormone produced during pregnancy by the developing placenta. - Its presence indicates pregnancy and is not a marker for **ovarian reserve**. *Placental alkaline phosphatase* - **Placental alkaline phosphatase (PLAP)** is an enzyme produced by the placenta. - It serves as a biological marker for certain cancers (e.g., germ cell tumors) and sometimes for placental function, but not **ovarian reserve**. *Serum estradiol* - **Serum estradiol** levels fluctuate significantly throughout the menstrual cycle and are influenced by numerous factors. - While **Day 3 estradiol** combined with FSH was historically used for ovarian reserve assessment, elevated levels can indicate poor reserve (due to early follicular recruitment). - However, it is **not as reliable or cycle-independent as AMH** for assessing the overall **follicle pool**.

Q: Polycystic ovarian syndrome is associated with the following except

Ovarian carcinoma. ***Ovarian carcinoma*** - While polycystic ovarian syndrome (PCOS) increases the risk of **endometrial hyperplasia** and subsequently **endometrial carcinoma** due to unopposed estrogen, it is **not directly associated with an increased risk of ovarian carcinoma**. - Ovarian carcinoma is a distinct entity with different risk factors, and PCOS does not typically predispose to it. *Obesity* - **Obesity**, particularly central obesity, is highly prevalent in women with PCOS, affecting many metabolic and hormonal aspects of the syndrome. - It contributes to **insulin resistance**, which is a key feature of PCOS and exacerbates its symptoms. *Infertility* - **Anovulation** or oligo-ovulation, a hallmark of PCOS, directly leads to **infertility** in many affected women. - The hormonal imbalances in PCOS interfere with normal follicular development and ovulation. *Endometrial hyperplasia* - The **unopposed estrogen stimulation** resulting from chronic anovulation in PCOS leads to continuous endometrial proliferation without regular shedding. - This persistent stimulation increases the risk of developing **endometrial hyperplasia**, which can be a precursor to endometrial carcinoma.

Q: The "fern pattern" of cervical mucus seen in the first half of menstrual cycle is because of

Low mucoprotein level. ***Low mucoprotein level*** - The **fern pattern** is formed by the crystallization of **sodium chloride** in the presence of **estrogen** and a relatively **low mucoprotein content** in cervical mucus. - During the proliferative phase, high estrogen levels increase the fluid and electrolyte content relative to mucoproteins, facilitating this distinct crystallization. - **Key concept**: While both high NaCl and low mucoprotein are present, it is the **low mucoprotein** that is the distinguishing factor allowing crystallization to occur. *Low sodium chloride level* - A low sodium chloride level would lead to **less crystallization**, not the characteristic fern pattern. - The presence of sodium chloride is crucial for forming the crystalline structure. *High sodium chloride level* - While sodium chloride is indeed **elevated during the follicular phase** and necessary for ferning, this alone is not the defining reason for the fern pattern. - Sodium chloride is present throughout the menstrual cycle; the key factor is the **reduced mucoprotein** that allows unimpeded crystallization. - Both high NaCl AND low mucoprotein work together, but the **low mucoprotein is the distinguishing feature** that permits the crystallization to manifest as ferning. *High mucoprotein level* - A high mucoprotein level would **interfere with the crystallization** of sodium chloride, preventing the formation of a clear fern pattern. - This occurs during the luteal phase when progesterone increases mucoproteins, inhibiting ferning.

Q: Success of tubal re-canalization is best with :

Laparoscopic ring application. ***Laparoscopic ring application (Falope ring/Tubal clips)*** - Mechanical occlusion methods (clips and rings) cause **minimal tissue destruction**, typically affecting only **2-3 cm** of the fallopian tube. - The tubal segments remain relatively **healthy and undamaged**, with minimal scarring and fibrosis. - Reversal success rates are **highest at 70-90%** due to the preservation of tubal architecture and length. - These methods are considered the **most reversible** form of tubal sterilization. *Pomeroy's technique* - Involves excision of a tubal loop (approximately 3-4 cm) with ligation, causing moderate tissue damage. - The cut ends heal by scarring, and some tubal length is permanently lost. - Reversal success rates are moderate at **60-70%**. - More tissue damage than clip/ring methods but still reasonably reversible. *Uchida's technique* - Involves separating the serosa from the muscularis, ligating and excising a **larger segment** of the tube (4-5 cm). - Creates more extensive tissue damage with greater tubal length loss. - Reversal success rates are lower at **40-50%** due to the complexity and extent of tissue disruption. *Fimbriectomy* - Involves complete removal of the **fimbrial end** of the fallopian tube, which is essential for ovum pickup. - Even if re-anastomosis is technically successful, the **absence of fimbriae** results in extremely poor functional outcomes. - Reversal success rates are very poor at **<20%**, making this the least reversible sterilization method.

Question 1

Which of the following statements about hysterosalpingography, as a diagnostic procedure, are correct?
I. Tubal patency assessment following tuboplasty operation
II. Diagnosis of uterine synechiae
III. Detection of IUD
IV. Diagnosis of subserosal fibroid

Select the answer using the code given below :

Accepted Answer

I, II and III

Answer

I, II and IV

Answer

II, III and IV

Answer

I, III and IV

Question 2

A 27-year-old female married for 3 years regularly cohabiting with husband presents to Gynaecology OPD with complaints of inability to conceive for 2 years. During clinical evaluation hysterosalpingography was done which revealed irregular outline of uterine cavity and rigid fallopian tubes with nodulations. Most likely cause for this condition is :

Accepted Answer

Genital Tuberculosis

Answer

Syphilis

Answer

Genital Herpes

Answer

Gonorrhoea

Question 3

Which of the following days of menstrual cycle is best for endometrial sampling to diagnose ovulation?

Accepted Answer

21st - 23rd day

Answer

12th - 14th day

Answer

8th - 10th day

Answer

16th - 20th day

Question 4

Which of the following are factors for poor outcome following tuboplasty?

1. Dense pelvic adhesions
2. Length of reconstructed tube less than 4 cm
3. Bilateral hydrosalpinx
4. Reversal after 5 years of sterilization procedure

Select the correct answer using the code given below.

Accepted Answer

1, 2 and 3

Answer

1, 2 and 4

Answer

2, 3 and 4

Answer

1, 3 and 4

Question 5

Which of the following are useful investigations for diagnosis of unresponsive endometrium as a cause of primary amenorrhoea?

1. Karyotype
2. Progesterone challenge test
3. Hormonal studies
4. Hysterosalpingography

Select the correct answer using the code given below.

Accepted Answer

1, 2 and 3

Answer

2, 3 and 4

Answer

1, 2 and 4

Answer

1, 3 and 4

Question 6

What is the most common first-line investigation used to assess the patency of fallopian tubes?

Accepted Answer

Hysterosalpingogram

Answer

Sonohysterogram

Answer

Laparoscopic chromopertubation

Answer

CT scan

Question 7

Which of the following is the marker of ovarian reserve?

Accepted Answer

Anti-Mullerian hormone

Answer

β-hCG

Answer

Placental alkaline phosphatase

Answer

Serum estradiol

Question 8

Polycystic ovarian syndrome is associated with the following except

Accepted Answer

Ovarian carcinoma

Answer

Obesity

Answer

Infertility

Answer

Endometrial hyperplasia

Question 9

The "fern pattern" of cervical mucus seen in the first half of menstrual cycle is because of

Accepted Answer

Low mucoprotein level

Answer

Low sodium chloride level

Answer

High sodium chloride level

Answer

High mucoprotein level

Question 10

Success of tubal re-canalization is best with :

Accepted Answer

Laparoscopic ring application

Answer

Uchida's technique

Answer

Fimbriectomy

Answer

Pomeroy's technique

Fertility and Infertility — MCQs

Fertility and Infertility — MCQs

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