Fertility and Infertility — MCQs

Fertility and Infertility Indian Medical PG Practice Questions and MCQs

Question 211: Which of the following is correct regarding obesity and infertility?

A. It is always associated with endometrial atrophy
B. It is associated with hypergonadotropic hypogonadism
C. There is no change in HPO axis
D. It is associated with hypogonadotropic hypogonadism (Correct Answer)

Explanation: ***It is associated with hypogonadotropic hypogonadism*** - **Obesity-related infertility** in men often leads to **decreased testosterone** levels and **impaired spermatogenesis**, driven by altered adipose tissue function affecting the **hypothalamic-pituitary-gonadal (HPG) axis**. - Adipose tissue in obese individuals produces more **estrogen** and **inflammatory cytokines**, which can suppress **gonadotropin-releasing hormone (GnRH)**, leading to reduced LH and FSH levels from the pituitary and subsequently lower testosterone production by the testes. *It is always associated with endometrial atrophy* - While obesity can affect endometrial health, it is more commonly associated with **endometrial hyperplasia** due to increased **estrogen production** from peripheral fat, leading to unopposed estrogen stimulation. - **Endometrial atrophy** is typically seen in states of severe chronic estrogen deficiency, such as post-menopause or severe hypogonadism not directly related to obese states. *It is associated with hypergonadotropic hypogonadism* - **Hypergonadotropic hypogonadism** is characterized by low testosterone (or estrogen) with **elevated LH and FSH levels**, indicating primary gonadal failure (e.g., testicular failure or ovarian failure) where the pituitary is overproducing gonadotropins in an attempt to stimulate the failing gonads. - In obesity, the issue is often at the level of the hypothalamus or pituitary (central), leading to **reduced** rather than elevated gonadotropins. *There is no change in HPO axis* - Obesity significantly impacts the **hypothalamic-pituitary-ovarian (HPO)** axis in women and the **hypothalamic-pituitary-testicular (HPT)** axis in men. - Alterations include increased **leptin** and **insulin resistance**, leading to changes in **GnRH pulsatility**, which disrupts LH and FSH secretion and subsequent gonadal steroid production, thereby affecting fertility.

Question 212: What are Spiegelberg's criteria for diagnosis of ovarian pregnancy? 1. Tube on the affected side must be intact 2. Gestational sac must be in the position of ovary 3. Ovary is connected to uterus by utero-ovarian ligament 4. Ovarian tissue must be detected on the wall on histological examination

A. 1, 2 and 3 only
B. 1, 2, 3 and 4 (Correct Answer)
C. 2, 3 and 4 only
D. 1 and 4 only

Explanation: ***1, 2, 3 and 4*** * **Spiegelberg's criteria** are the established diagnostic criteria for **ovarian pregnancy**, first described in 1878. * All four criteria must be met for diagnosis: **(1) intact fallopian tube** on the affected side (rules out tubal pregnancy), **(2) gestational sac must occupy the position of the ovary**, **(3) the ovary must be connected to the uterus by the utero-ovarian ligament** (confirms normal anatomical position), and **(4) ovarian tissue must be histologically identified in the wall of the gestational sac** (definitive confirmation). * The **histological confirmation** of ovarian tissue is essential for definitive diagnosis and distinguishes it from other ectopic pregnancies. *1, 2 and 3 only* * While these three criteria establish the anatomical location and rule out tubal pregnancy, **histological confirmation** of ovarian tissue within the gestational sac wall (criterion 4) is essential for definitive diagnosis. * Without histological proof, other extrauterine pregnancies (such as advanced tubal pregnancies involving the ovary secondarily) could mimic the clinical and imaging features. *2, 3 and 4 only* * The **intact ipsilateral fallopian tube** (criterion 1) is critical for differentiating primary ovarian pregnancy from tubal pregnancy with secondary ovarian involvement. * Without confirming tube integrity, a tubal ectopic that has eroded into or adhered to ovarian tissue cannot be definitively excluded. *1 and 4 only* * These two criteria alone are insufficient; the gestational sac must be demonstrably located in the position of the ovary (criterion 2) and the ovary must maintain its normal anatomical connection to the uterus (criterion 3). * Missing the specific ovarian location and anatomical confirmation would lead to incomplete diagnosis and potential confusion with other forms of ectopic pregnancy.

Question 213: Which one of the following causes the greatest risk of ectopic pregnancy?

A. Previous ectopic pregnancy (Correct Answer)
B. Intrauterine contraceptive devices use
C. Previous normal delivery
D. Previous medical termination of pregnancy

Explanation: ***Previous ectopic pregnancy*** - A history of prior ectopic pregnancy significantly increases the risk of a **recurrent ectopic pregnancy** due to potential **tubal damage** from the previous event. - This is considered the **highest risk factor** among the choices provided because it indicates a pre-existing vulnerability in the reproductive system. *Intrauterine contraceptive devices use* - While IUDs do not cause ectopic pregnancies, they **prevent intrauterine pregnancies** more effectively than ectopic ones, leading to a higher proportion of pregnancies being ectopic if conception occurs. - The absolute risk of an ectopic pregnancy with an IUD in place is still **lower than in women not using contraception** but the ratio of ectopic to intrauterine pregnancies is higher. *Previous normal delivery* - A history of previous normal delivery is generally **protective against ectopic pregnancy**, as it suggests healthy tubal function and uterine environment. - This factor has **no association** with an increased risk of ectopic pregnancy. *Previous medical termination of pregnancy* - There is generally **no significant increased risk** of ectopic pregnancy associated with a single medical termination of pregnancy, especially when performed early in gestation. - Repeated or complicated terminations, especially surgical, *could* theoretically increase risk due to **tubal damage or inflammation**, but medical termination typically carries little to no added risk.

Question 214: Rokitansky-Küster-Hauser syndrome is associated with:

A. All of the options (Correct Answer)
B. Normal hormone profile
C. Primary amenorrhoea with mullerian agenesis
D. Renal abnormalities

Explanation: ***All of the options*** Rokitansky-Küster-Hauser (MRKH) syndrome is associated with **all three features** listed, making this the correct answer. **Primary amenorrhea with Müllerian agenesis:** - This is the **hallmark feature** of MRKH syndrome - Müllerian agenesis leads to **absent or underdeveloped uterus and upper two-thirds of vagina** - Patients present with **primary amenorrhea** despite normal pubertal development - The external genitalia and lower vagina are normal **Normal hormone profile:** - MRKH syndrome patients have **functioning ovaries** with normal oogenesis - **Normal 46,XX karyotype** - **Normal FSH, LH, estrogen, and progesterone levels** - Normal development of **secondary sexual characteristics** (breast development, pubic hair, normal height) - This distinguishes MRKH from androgen insensitivity syndrome **Renal abnormalities:** - Present in **15-30% of MRKH type 1** cases - Present in **up to 50% of MRKH type 2** (MURCS association - Müllerian, Renal, Cervicothoracic Somite abnormalities) - Common anomalies include **renal agenesis** (unilateral or bilateral), **ectopic kidney**, **horseshoe kidney**, and **hydronephrosis** - Renal ultrasound is recommended as part of initial evaluation **Why "All of the options" is correct:** All three features—primary amenorrhea with Müllerian agenesis, normal hormone profile, and renal abnormalities—are characteristic associations of MRKH syndrome, making this the most complete and accurate answer.

Question 215: Antisperm antibodies are usually present in:

A. Vagina
B. Fallopian tube
C. Uterus
D. Cervix (Correct Answer)

Explanation: ***Cervix*** - The **cervical mucus** is the most clinically significant site in the **female reproductive tract** where **antisperm antibodies** interfere with fertility. - These antibodies can **agglutinate sperm**, **immobilize sperm**, or reduce their ability to penetrate through cervical mucus and reach the ovum, contributing to **immunological infertility**. - In the context of local immune responses affecting fertilization, the **cervix** acts as a critical immunological barrier where ASAs are detected and clinically relevant. - Note: Antisperm antibodies can also be detected in **serum** (blood) and are commonly found in **seminal plasma** in males, but among reproductive tract sites in females, the **cervix** is the primary location of clinical significance. *Vagina* - The **acidic environment** (pH 3.8-4.5) of the vagina is generally hostile to sperm, but it is not a primary site for antisperm antibody formation or action. - While some immune cells exist, the vagina's protective function relies more on acidic pH and normal flora rather than specific antisperm antibodies. *Fallopian tube* - The fallopian tubes are primarily involved in **sperm transport**, **fertilization**, and **embryo transport**, but are not a primary site where antisperm antibodies cause clinical infertility problems. - Although sperm encounter the tubal environment, the **cervical mucus** at the cervix acts as a more significant and earlier immunological barrier. *Uterus* - The uterine cavity is generally more accommodating to sperm after they pass through the cervical barrier, and is not the primary site for antisperm antibody-mediated infertility. - The **cervix** serves as the critical immunological checkpoint before sperm reach the uterine environment.

Question 216: Which of the following is not a characteristic of Mayer-Rokitansky-Küster-Hauser syndrome?

A. Skeletal abnormalities
B. Renal abnormalities
C. Cardiac anomalies (Correct Answer)
D. Mullerian duct aplasia

Explanation: ***Cardiac anomalies*** - While other systemic abnormalities can be associated with MRKH syndrome, **cardiac anomalies** are generally not considered a characteristic feature. - MRKH syndrome primarily affects the **Müllerian ducts** and is often linked to renal and skeletal issues due to common developmental origins. *Skeletal abnormalities* - **Skeletal abnormalities**, particularly of the **vertebral column** (e.g., scoliosis, fused vertebrae), are commonly associated with MRKH syndrome. - This association is thought to arise from defects in the paraxial mesoderm during embryonic development, which affects both skeletal and Müllerian structures. *Renal abnormalities* - Around 30-50% of individuals with MRKH syndrome also have **renal anomalies**, such as **unilateral renal agenesis**, horseshoe kidney, or renal ectopia. - These abnormalities are due to the close developmental proximity and shared mesodermal origin of the Müllerian ducts and the **urogenital system**. *Mullerian duct aplasia* - **Müllerian duct aplasia** is the **defining characteristic** of MRKH syndrome, leading to the absence or hypoplasia of the uterus and upper vagina. - Individuals typically present with **primary amenorrhea** despite having normal secondary sexual characteristics and functioning ovaries.

Question 217: A 25 year old infertile woman is noted to have blocked fallopian tubes on Hysterosalpingography. Which of the following is the best next step for this woman?

A. Clomiphene citrate therapy
B. Laparoscopy (Correct Answer)
C. Intrauterine insemination
D. Gonadotropin therapy

Explanation: ***Laparoscopy*** - A **blocked fallopian tube** identified on hysterosalpingography (HSG) requires direct visualization to confirm the diagnosis, assess the extent of the blockage, identify any associated pelvic pathology (adhesions, endometriosis), and potentially perform surgical correction (e.g., salpingostomy, fimbrioplasty, adhesiolysis). - Laparoscopy allows for **definitive diagnosis** of tubal pathology and can be therapeutic. It is particularly indicated when there is suspicion of correctable pathology or when the patient prefers attempting natural conception. - **Note**: In modern practice, IVF is increasingly considered as first-line for bilateral tubal disease, but laparoscopy remains important for diagnostic purposes and when surgical correction is feasible. *Clomiphene citrate therapy* - This therapy is primarily used to induce **ovulation** in anovulatory infertility, which is not the primary issue when blocked fallopian tubes are identified. - It would be ineffective in overcoming a physical **tubal obstruction**, as sperm and egg cannot meet regardless of ovulation status. *Intrauterine insemination* - IUI involves placing sperm directly into the uterus, bypassing cervical factors, but it still requires at least one **patent fallopian tube** for fertilization to occur. - With blocked fallopian tubes, IUI would not address the problem of the egg and sperm being unable to meet, making it an inappropriate choice. *Gonadotropin therapy* - Gonadotropins (FSH and LH) are used to stimulate **follicle development** and ovulation, similar to clomiphene but often for more resistant cases or controlled ovarian hyperstimulation. - This therapy does not resolve **tubal blockages** and would not be effective in achieving pregnancy in the presence of blocked fallopian tubes without patent tubes for fertilization.

Question 218: A 29 year old woman is noted to have three consecutive first trimester spontaneous abortions. Examination reveals fibroid uterus. Which of the following types of uterine fibroids would most likely lead to recurrent abortions?

A. Submucosal (Correct Answer)
B. Cervical
C. Intramural
D. Subserosal

Explanation: ***Submucosal*** - **Submucosal fibroids** are located directly beneath the **endometrium** and can protrude into the uterine cavity, disrupting the normal implantation site and early fetal development. - Their presence significantly increases the risk of **implantation failure** and **recurrent first-trimester spontaneous abortions** due to mechanical distortion and altered uterine blood flow. *Cervical* - **Cervical fibroids** are rare and located in the uterine cervix; while they can cause symptoms like bleeding or difficulty with delivery, they are less likely to directly impact **early implantation** or cause **recurrent first-trimester abortions**. - Their primary impact is often related to labor and delivery complications rather than early pregnancy loss. *Intramural* - **Intramural fibroids** are located within the muscular wall of the uterus and are the most common type. While large or numerous intramural fibroids can sometimes contribute to pregnancy complications, their direct impact on **recurrent first-trimester abortions** is generally less significant compared to submucosal fibroids. - Their effect on fertility often depends on their size, number, and proximity to the **endometrial cavity**. *Subserosal* - **Subserosal fibroids** are located on the outer surface of the uterus, beneath the serosa, and typically grow outwards. - They usually have **minimal to no impact** on implantation or early pregnancy development, thus they are unlikely to be a cause of **recurrent first-trimester abortions**.

Question 219: The most common cause of early spontaneous abortion is:

A. Teratogens
B. Endocrine disorder
C. Infection
D. Chromosomal abnormality (Correct Answer)

Explanation: ***Chromosomal abnormality*** - **Chromosomal abnormalities**, such as aneuploidy (e.g., trisomy, monosomy), are responsible for approximately 50-70% of all **early spontaneous abortions**. - These abnormalities often result in **non-viable embryos** or fetuses, leading to pregnancy loss before 12-20 weeks of gestation. *Teratogens* - **Teratogens** are agents that can cause birth defects, but they are a less common cause of **early spontaneous abortion** compared to chromosomal abnormalities. - While they can lead to fetal demise, their primary impact is often on **fetal development** rather than embryonic non-viability. *Endocrine disorder* - **Endocrine disorders** like uncontrolled diabetes or thyroid disease can increase the risk of spontaneous abortion, but they are not the **most common cause**. - These factors tend to contribute to a smaller percentage of **early pregnancy losses** compared to genetic errors. *Infection* - Certain **infections** (e.g., TORCH infections, bacterial vaginosis) can cause spontaneous abortion, especially if systemic or severe. - However, similar to endocrine disorders, infections are a less frequent cause of **early spontaneous abortion** than chromosomal abnormalities.

Question 220: Which one of the following is NOT a common cause of recurrent abortions?

A. Antiphospholipid syndrome
B. Chromosomal abnormality
C. TORCH group of infections
D. Maternal diabetes (Correct Answer)

Explanation: ***Maternal diabetes*** - While uncontrolled diabetes can increase the risk of **miscarriage** and **birth defects** in general, it is typically not considered a common or direct cause of *recurrent abortions* (defined as three or more consecutive pregnancy losses). - Its effects are often seen in isolated miscarriages or specific fetal anomalies rather than a pattern of repeated losses. *Antiphospholipid syndrome* - This is a well-established cause of recurrent abortions due to the formation of **thrombi** in the placental circulation, leading to impaired blood flow and fetal demise. - It involves the presence of **antiphospholipid antibodies** that interfere with normal pregnancy progression. *Chromosomal abnormality* - Both parental and embryonic chromosomal abnormalities are a very common cause of recurrent pregnancy loss, particularly in the **first trimester**. - These abnormalities often result in non-viable embryos, leading to spontaneous abortion. *TORCH group of infections* - Infections like **Toxoplasmosis, Other (syphilis, parvovirus), Rubella, Cytomegalovirus (CMV), and Herpes simplex virus (HSV)** can cause significant fetal damage and pregnancy loss. - While they can lead to miscarriage, they are generally associated with sporadic miscarriages or specific fetal syndromes rather than recurring abortions in consecutive pregnancies.

Practice by Chapter

Reproductive Physiology

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Evaluation of the Infertile Couple

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Male Factor Infertility

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Female Factor Infertility

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Ovulatory Disorders

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Tubal and Peritoneal Factors

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Uterine Factors

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Unexplained Infertility

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Assisted Reproductive Technologies

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Psychological Aspects of Infertility

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