Fertility and Infertility Practice Questions

Q: A 28-year old woman comes with infertility. Husband's semen analysis is normal. Endometrial biopsy shows secretory changes with no evidence of tuberculosis. On hysterosalpingography both tubes show tubal blockage. What should be the next step in management?

Diagnostic laparoscopy and chromo-pertubation. ***Diagnostic laparoscopy and chromo-pertubation*** - This procedure directly visualizes the fallopian tubes and surrounding pelvic structures, allowing for definitive confirmation of tubal blockage and identification of potential causes like **endometriosis** or **adhesions**. - **Chromo-pertubation** involves injecting a dye through the cervix to assess tubal patency and identify the exact location and nature of the blockage. *IVF* - While IVF is a viable option for tubal factor infertility, it is generally considered after a more thorough diagnostic workup, especially when the cause of blockage is unknown and potentially treatable. - Proceeding directly to IVF without assessing the possibility of surgical correction might be premature and miss an opportunity for natural conception or a less invasive intervention. *Tuboplasty* - **Tuboplasty** is a surgical procedure to repair or reconstruct damaged fallopian tubes. - However, its success depends on the extent of damage and the specific type of blockage, which can only be determined after a diagnostic evaluation like laparoscopy. *ICSI* - **ICSI (Intracytoplasmic Sperm Injection)** is a specialized form of IVF primarily used for severe male factor infertility, not tubal blockage, especially when the husband's semen analysis is normal. - While ICSI can be part of an IVF cycle, it's not the primary next step for diagnosing or treating tubal blockage in a woman with normal male factor.

Q: Asherman's syndrome typically results from

Excessive curettage during abortion. ***Excessive curettage during abortion*** - **Asherman's syndrome** is characterized by the formation of **intrauterine adhesions** or **synechiae** - This results from trauma to the **basal layer of the endometrium** during procedures like excessive or repeated curettage following abortion, miscarriage, or childbirth - The curettage causes scarring that leads to partial or complete obliteration of the uterine cavity - **Most common cause** of intrauterine adhesions and presents with amenorrhea, hypomenorrhea, or infertility *Post-partum haemorrhage* - While post-partum hemorrhage can lead to uterine procedures, it is not a direct cause of Asherman's syndrome itself - The syndrome is caused by the **curettage performed** to manage the hemorrhage or retained products, not the hemorrhage directly - PPH is an indication for intervention, but the procedural trauma causes the adhesions *Prolonged usage of oral contraceptives* - Oral contraceptives work by suppressing ovulation and altering the endometrial lining - They cause endometrial thinning but do not cause physical trauma to the endometrium - They do not lead to the formation of intrauterine adhesions characteristic of Asherman's syndrome *Use of intrauterine contraceptive device* - An **intrauterine contraceptive device (IUD)** prevents pregnancy by causing a sterile inflammatory reaction - While IUDs can cause endometritis or perforation in rare cases, they do not typically lead to the severe endometrial trauma and subsequent adhesion formation seen in Asherman's syndrome - Asherman's syndrome requires basal endometrial damage, which IUDs do not typically cause

Q: A 25-year-old woman with a history of three consecutive abortions has been investigated thoroughly to determine the cause of recurrent pregnancy loss. In the absence of a demonstrable cause, what is the chance of a viable birth in subsequent pregnancy?

60%. ***60%*** - In cases of **unexplained recurrent pregnancy loss** (3 consecutive miscarriages with no identifiable cause), approximately **60-70%** of women will achieve a successful live birth in their subsequent pregnancy with supportive care. - This favorable prognosis reflects that many recurrent losses are due to **sporadic chromosomal abnormalities** rather than persistent underlying pathology. - **Unexplained RPL** actually has a better prognosis than explained RPL, as there is no persistent pathological factor. - Supportive care including reassurance, regular monitoring, and psychological support improves outcomes. *40%* - This underestimates the success rate for unexplained recurrent pregnancy loss. - A **40%** success rate would suggest a poorer prognosis more typical of cases with **identified but untreated underlying causes** or more complex pathology. - Current evidence supports a higher success rate (60-70%) for unexplained cases. *20-30%* - This represents a significantly poor prognosis not typical for unexplained recurrent pregnancy loss. - Such low rates might be seen in cases with **severe untreated underlying conditions** such as antiphospholipid syndrome without treatment or structural uterine anomalies. - This does not reflect the natural history of unexplained RPL. *Less than 20%* - This represents an extremely poor prognosis inconsistent with unexplained recurrent pregnancy loss. - Such rates would only be expected in cases with **severe, uncorrectable pathology** or multiple comorbidities. - The question specifically states "absence of a demonstrable cause," making this option incorrect.

Q: A nulliparous woman presents with acute lower abdominal pain. She has a history of missed periods. The ultrasound examination shows an empty uterus. The cervical movements are very tender. The vital signs are stable. How will you manage her?

Admit her for observation. ***Admit her for observation*** - The patient presents with classic symptoms of a **potential ectopic pregnancy** (missed periods, lower abdominal pain, empty uterus on ultrasound, cervical motion tenderness). However, her **vital signs are stable**, indicating she is currently hemodynamically stable. - Admission for observation allows for close monitoring of vital signs, serial **beta-hCG measurements**, and repeat ultrasounds to confirm the diagnosis and assess for any signs of rupture, enabling timely intervention if needed. *Start a pitocin drip* - **Pitocin (oxytocin)** is used to induce labor or manage postpartum hemorrhage, as it contracts the uterus. - In a suspected ectopic pregnancy with an empty uterus, administering oxytocin would be ineffective and potentially harmful if a **tubal pregnancy** is present. *Treat her as a case of Pelvic Inflammatory Disease.* - While PID can cause lower abdominal pain and cervical motion tenderness, the history of **missed periods** and an **empty uterus on ultrasound** strongly suggest pregnancy complications rather than infection. - Treating for PID without ruling out ectopic pregnancy could lead to a catastrophic delay in managing a ruptured ectopic pregnancy. *Perform a laparotomy* - A laparotomy is an **invasive surgical procedure** typically reserved for confirmed or highly suspected cases of ruptured ectopic pregnancy or other acute abdominal emergencies. - Given the patient's **stable vital signs** and the possibility of a non-ruptured ectopic or even a miscarriage, immediate laparotomy is premature without further diagnostic assessment.

Q: In a lady with a regular 28-day menstrual cycle, what is the 'safe period'?

First and last seven days. ***First and last seven days*** - In a typical 28-day cycle, **ovulation** usually occurs around day 14. Sperm can survive for up to 5 days, and the egg is viable for about 24 hours. Therefore, avoiding unprotected intercourse from approximately day 7 to day 19 would be considered within the fertile window. The "safe period" refers to days with a lower probability of conception. - The **first seven days** (including menstruation) and the **last seven days** (preceding the next menstrual period) are generally considered the least fertile times, as they are furthest from ovulation. *Initial 14 days* - This period includes the follicular phase, leading up to and including **ovulation**. - The **fertile window** typically encompasses several days before ovulation, the day of ovulation, and the day after, making the initial 14 days a high-risk period, not a safe one. *Later 14 days* - This period includes the **luteal phase** after ovulation has occurred. - While the latter part of this period (days 21-28) is generally less fertile, the days immediately following ovulation (around days 15-18) still carry a risk of conception if the egg is viable or if ovulation was delayed. *First seven days only* - While the first seven days are generally considered a **low-risk period**, relying solely on this neglects the increased risk shortly before and during ovulation. - This option only covers a portion of the "safe period" and does not account for the reduced fertility towards the end of the menstrual cycle.

Q: In a 28 year old infertile woman with anovulation, the following parameters will indicate ovulation EXCEPT:

Insler score. ***Insler score*** - The **Insler score** assesses cervical mucus quality (amount, ferning, spinnbarkeit, cellularity) and is used to evaluate the **potential for sperm penetration**. - While it reflects **estrogen effects** on the cervix, it does not directly confirm *ovulation* itself but rather the *cervical environment* suitable for conception. *Serum estradiol levels* - **Estradiol levels** typically peak *before ovulation* (during the follicular phase) and then decline, followed by a secondary rise during the luteal phase due to the corpus luteum. - While reflecting **follicle development**, a singular estradiol level doesn't definitively confirm the *occurrence* of ovulation, but rather the hormonal changes leading up to it. *Vaginal smear* - A **vaginal smear** can show changes in **cytology** (e.g., increased superficial cells, decreased parabasal cells) under dominant *estrogen influence* in the pre-ovulatory phase. - Post-ovulation, progesterone causes changes like an increase in basal cells and clumping; however, like estradiol, it indicates hormonal milieu rather than direct evidence of *ovulation*. *Urinary LH levels* - A surge in **luteinizing hormone (LH)** is the direct trigger for **ovulation**, typically occurring 24-36 hours *before* the actual release of the egg. - Detecting the **LH surge** in urine is a widely used and reliable method to predict the imminent occurrence of ovulation.

Q: Cervical mucus examination of a 22 year old infertile woman is done to look for all the following except:

Presence of HPV. ***Presence of HPV*** - Cervical mucus examination is primarily used to assess the **physical properties** of mucus related to fertility, such as **consistency**, **elasticity**, and **crystallization**. - Detecting the **human papillomavirus (HPV)** typically involves specific viral DNA tests (e.g., PCR) or cytology (Pap smear) for cellular changes, not a routine mucus examination. *Spinnbarkeit* - This refers to the **elasticity** or **stretchability** of cervical mucus, which increases around **ovulation** due to rising estrogen levels, facilitating sperm transport. - Assessing spinnbarkeit is a standard part of evaluating cervical mucus quality in infertility workups. *Cellularity of mucus* - The cellularity of cervical mucus, particularly the presence of a high number of **leukocytes** (white blood cells), can indicate **inflammation** or **infection**, which might impair sperm viability and function. - This assessment helps in identifying potential reproductive tract infections affecting fertility. *Ferning* - This phenomenon describes the characteristic **fern-like crystallization pattern** of dried cervical mucus, which is prominent at **mid-cycle** due to high estrogen levels and low progesterone. - The presence or absence of ferning helps in identifying the **ovulatory phase** and assessing hormonal influence on cervical mucus.

Q: A woman undergoing treatment of infertility presents with triplet pregnancy. The most probable drug given to her for treatment of infertility would have been:

Inj HMG. ***Inj HMG*** - **Human menopausal gonadotropin (HMG)**, which contains both **FSH and LH**, stimulates the development of multiple ovarian follicles. - This increased follicular development, when followed by ovulation, significantly raises the risk of **multiple pregnancies**, including triplets, in women undergoing infertility treatment. *Inj GnRH analogue* - **GnRH analogues** are primarily used to suppress natural gonadotropin release and prevent premature ovulation, often as part of controlled ovarian hyperstimulation. - While used in infertility treatments, their direct action is not typically to induce **multiple ovulation** leading to triplets; rather, they regulate the cycle before other stimulating agents are given. *Clomiphene Citrate* - **Clomiphene citrate** is an oral anti-estrogen that works by increasing natural FSH and LH production, leading to the development of one or a few follicles. - Although it can cause **twin pregnancies** in about 5-10% of cases, the incidence of triplets or higher-order multiples is much lower (less than 1%), making it less likely to be the cause of triplets than HMG. *Inj hCG* - **Human chorionic gonadotropin (hCG)** is given to trigger **final oocyte maturation and ovulation** once follicles have reached an appropriate size after stimulation with other agents. - While essential for ovulation, hCG itself does not stimulate follicular development and therefore isn't the primary drug responsible for the **multiple follicle growth** that leads to triplet pregnancy.

Q: Which one of the following is NOT a cause of recurrent spontaneous abortion?

Rubella infection. ***Rubella infection*** - While rubella infection during pregnancy can lead to serious **congenital anomalies** (congenital rubella syndrome) and fetal death, it is **NOT a typical cause of recurrent spontaneous abortions** - Rubella primarily causes **single pregnancy loss** or teratogenic effects in ongoing pregnancies, rather than the pattern of repeated losses seen in recurrent abortion - The infection does not create the persistent maternal factors (immunological, thrombophilic, or anatomical) that characterize causes of recurrent pregnancy loss *Antiphospholipid syndrome* - This autoimmune disorder is a **well-established cause of recurrent pregnancy loss** (accounts for 10-15% of cases) - Antiphospholipid antibodies cause **thrombosis in placental vasculature**, leading to placental insufficiency and infarction - Results in repeated pregnancy losses, typically in the second trimester *Inherited thrombophilia* - Conditions like **Factor V Leiden mutation** and **prothrombin gene mutation** increase thrombotic risk - Cause **placental microthrombi** that compromise fetal blood supply - Recognized as a cause of recurrent spontaneous abortion, though the association is stronger for late pregnancy loss *Chromosomal abnormality* - **Parental balanced translocations** are an important cause of recurrent spontaneous abortion (3-5% of couples) - While random fetal aneuploidy is the most common cause of sporadic abortion, parental chromosomal rearrangements lead to **recurrent unbalanced offspring** and repeated losses - Karyotyping of both partners is recommended after recurrent pregnancy loss

Q: Which one of the following is an abnormal parameter in accordance with WHO Semen Analysis Criteria (Normal reference value)?

Volume 14%* - WHO criteria state that **≥ 4% of sperms should have normal morphology** (strict criteria) - A morphology of >14% is **well within the normal range** (more than 3 times the threshold) - This represents a normal finding, not an abnormality *Progressive forward motility of sperms > 50%* - WHO guidelines indicate that **progressive motility (PR) should be ≥ 32%** - Progressive forward motility of >50% is **significantly above the threshold** - This indicates excellent sperm motility and is a normal finding *Sperm concentration < 10 million/ml* - Normal reference value for sperm concentration is **≥ 15 million/ml** - While <10 million/ml would be considered abnormal (**oligozoospermia**), the question asks for "an abnormal parameter" - **Volume < 1.0 ml is the best answer** as it represents a more significant deviation from normal values (1.0 vs 1.5 ml threshold) compared to other parameters

Question 1

A 28-year old woman comes with infertility. Husband's semen analysis is normal. Endometrial biopsy shows secretory changes with no evidence of tuberculosis. On hysterosalpingography both tubes show tubal blockage. What should be the next step in management?

Accepted Answer

Diagnostic laparoscopy and chromo-pertubation

Answer

IVF

Answer

Tuboplasty

Answer

ICSI

Question 2

Asherman's syndrome typically results from

Accepted Answer

Excessive curettage during abortion

Answer

Post-partum haemorrhage

Answer

Prolonged usage of oral contraceptives

Answer

Use of intrauterine contraceptive device

Question 3

A 25-year-old woman with a history of three consecutive abortions has been investigated thoroughly to determine the cause of recurrent pregnancy loss. In the absence of a demonstrable cause, what is the chance of a viable birth in subsequent pregnancy?

Accepted Answer

60%

Answer

Less than 20%

Answer

40%

Answer

20-30%

Question 4

A nulliparous woman presents with acute lower abdominal pain. She has a history of missed periods. The ultrasound examination shows an empty uterus. The cervical movements are very tender. The vital signs are stable. How will you manage her?

Accepted Answer

Admit her for observation

Answer

Start a pitocin drip

Answer

Treat her as a case of Pelvic Inflammatory Disease.

Answer

Perform a laparotomy

Question 5

In a lady with a regular 28-day menstrual cycle, what is the 'safe period'?

Accepted Answer

First and last seven days

Answer

Initial 14 days

Answer

Later 14 days

Answer

First seven days only

Question 6

In a 28 year old infertile woman with anovulation, the following parameters will indicate ovulation EXCEPT:

Accepted Answer

Insler score

Answer

Serum estradiol levels

Answer

Vaginal smear

Answer

Urinary LH levels

Question 7

Cervical mucus examination of a 22 year old infertile woman is done to look for all the following except:

Accepted Answer

Presence of HPV

Answer

Spinnbarkeit

Answer

Cellularity of mucus

Answer

Ferning

Question 8

A woman undergoing treatment of infertility presents with triplet pregnancy. The most probable drug given to her for treatment of infertility would have been:

Accepted Answer

Inj HMG

Answer

Inj GnRH analogue

Answer

Clomiphene Citrate

Answer

Inj hCG

Question 9

Which one of the following is NOT a cause of recurrent spontaneous abortion?

Accepted Answer

Rubella infection

Answer

Antiphospholipid syndrome

Answer

Inherited thrombophilia

Answer

Chromosomal abnormality

Question 10

Which one of the following is an abnormal parameter in accordance with WHO Semen Analysis Criteria (Normal reference value)?

Accepted Answer

Volume < 1.0 ml

Answer

Normal morphology of sperms > 14%

Answer

Progressive forward motility of sperms > 50%

Answer

Sperm concentration < 10 million/ml

Fertility and Infertility — MCQs

Fertility and Infertility — MCQs

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